Every finding on record at Rock Creek Health and Rehabilitation

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (Resident #1) reviewed for infection control. The facility failed to ensure RN A used the proper handwashing technique while providing wound care for Resident #1 8/5/2026 at 10:39 AM. The facility failed to ensure RN A maintained enhanced barrier precautions when she performed wound care and provided incontinent care to Resident #1 on 8/5/2026 at 10:39 AM. The facility failed to ensure CNA B maintained enhanced barrier precautions on 8/5/2026 at 10:39 AM. CNA B exited Resident #1's room with soiled linen and a soiled brief that was not bagged and exited the room without removing her PPE (gown and gloves). These failures could place residents at risk of infection. Findings included: Record review of Resident #1's face sheet, dated 8/5/2026, indicated he was a [AGE] year-old male who admitted to the facility on [DATE] and readmitted to the facility on [DATE] with the diagnoses of Osteomyelitis (an infection in the bone, often caused by bacteria that reach the bone from outside the body), paraplegia (paralysis of the legs and lower body, typically caused by spinal injury or disease), pressure ulcers to left buttocks and sacral region (localized injury to the skin and/or underlying tissue that develops when soft tissue is compressed between a bony prominence and an external surface for a prolonged period of time, often due to pressure, or pressure combined with shear and/or friction), and muscle weakness. Record review of Resident #1's admission MDS assessment, dated 6/5/2026, indicated he usually understood others and was sometimes able to make himself understood. The MDS also indicated he had a BIMS score of 0 which meant he had severe cognitive impairment. The MDS also indicated he was dependent on staff for toileting and bathing, he required maximum assistance with bed mobility and required supervision assistance with eating. The MDS indicated Resident #1 had 2 Stage III pressure injuries that were not present on admission. The MDS indicated Resident #1 had 2 Stage IV pressure injuries that were not present on admission. Record review of Resident #1's care plan, dated 7/18/2026, indicated he had pressure ulcers and was at risk for infection, pain, and a decline in functional abilities with a goal to remain free from infection and interventions to provide wound care per physician's order. During an observation on 8/5/2026 at 10:39 AM, RN A was observed providing wound care to Resident #1. The resident had wounds to the left gluteal (an anatomy term that means relating to the buttocks) areas 1 and 2, right gluteal area, right hip, and sacrum (the sacral area is the region at the base of the spine, just above the tailbone and between the hip bones). RN A was assisted by CNA B. Prior to initiating wound care, RN A entered the resident's room wearing a gown and gloves. RN A and CNA B turned Resident #1 to the right side with maximum assistance. RN A removed the resident's soiled dressings, which were visibly moist with clear drainage. After removing the soiled dressings, RN A did not change gloves or perform hand hygiene before continuing with wound care. RN A cleansed all of the resident's wounds using a spray bottle labeled wound cleanser. RN A then used clean gauze to pat the wounds dry. The clean gauze was placed directly on the bedside table. During wound care, RN A touched her left ear and then touched the left side of her face while moving her hair behind her ear. RN A was wearing gloves during these actions. RN A subsequently changed gloves but did not perform hand hygiene before putting on the new gloves. RN A was observed blowing into a glove to open it before placing it on her hand. RN A then picked up prepared dressings and applied them to the resident's wounds. One prepared dressing was dropped. While wearing the same gloves, RN A picked up a ball of tissues from the top of a tissue box and placed the dropped dressing onto the tissues. RN A left the resident's room, to obtain a new dressing and supplies, while wearing the gown and gloves used during the wound-care procedure. RN A walked to the treatment cart and removed keys from her pants pocket. While wearing the same gloves, RN A touched multiple items on the cart, the cart handles, and the top of the trash can attached to the cart. RN A then returned to the resident's room without changing gloves or performing hand hygiene and applied the new dressing to Resident #1's right hip using the same gloves. RN A again left the resident's room without changing gloves or removing the gown. RN A walked across the hallway to a clean linen cart and removed a brief, bottom sheet, and draw sheet. RN A returned to Resident #1's room and proceeded to change the residents' linens and brief while wearing the same gloves. CNA B placed the dirty sheets and soiled brief on the floor at the foot of Resident #1's bed. The soiled brief was wrapped inside the dirty sheets. RN A and CNA B then pulled Resident #1 up in the bed. RN A subsequently left the resident's room while still wearing the same gloves and gown and requested assistance from another CNA to reposition the resident. CNA B then picked up the dirty sheets with the soiled diaper wrapped inside and carried the contaminated linen and brief out of the resident's room in her hands without placing the items in a designated linen bag or other appropriate container. CNA B walked out of the room and into hallway while carrying the soiled linen and brief. During an interview on 8/5/20262 at 11:10 AM, RN A said that she should not have walked out of the room with gown or gloves on and should have done hand hygiene and changed gloves more often during wound care. RN A said she should have used hand sanitizer or soap and water and changed gloves after she removed soiled dressings as well as a couple of other times. RN A said she also failed to remove gloves and gown when leaving and re-entering Resident #1's room. RN A said the failure placed others at risk due to spreading germs and causing infections to spread in the building as well as placed the resident at risk for wound infection. During an interview on 8/5/2026 at 12:02 PM, CNA B said she was not prepared when she went into the room to assist with holding Resident #1 on his side for a linen change. CNA B said that she should not have put the dirty linen or dirty brief on the floor and should have brought in a bag for each item to carry out separately. CNA B said she should not have removed the dirty linen and brief from the room without first placing them in separate plastic bags (the bag with the brief to placed in the trash; the bag with the linens to be placed in soiled linen compartment). CNA B said she should have removed her gown and gloves and washed her hands before exiting the room. CNA B said that she got everything contaminated by placing items on the floor and then transporting dirty items to barrels down the hallway and it could cause others to get really sick. During an interview on 8/5/2026 at 4:45 PM, the DON said the expectation was for staff to follow orders and specifications of Infection Control. While treatments were not sterile dressing changes, they were clean and should be treated as such. Staff should be adhering to guidelines while using proper protocol. The DON said with EBP should be used with personal care or with wound care, the gown needed to be used as well as gloves. The DON said when the gown and gloves were removed then it should be disposed of properly. The DON said the linen cart should never be touched with dirty gloves. The DON said that there have been in-services on infection control as well as hand hygiene. The DON said she was responsible for ensuring that infection control was followed and ensuring that PPE was worn as well as removed per protocol. The DON said that the risk was spreading germs throughout the building as well as causing an infection that could have secondary complications with the resident. During an interview on 8/5/2026 at 5:15 PM, the ADM said she expected the staff to use EBP and PPE while providing care as well as handwashing. The ADM said a resident or staff member could get sick or cross-contamination could make a resident ill. The ADM said she expected the staff to follow infection control procedures and adhere to the policies in place. Record review of the facility policy titled, Infection Control Plan: Overview, dated March of 2024, stated, Policy: The facility will establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection.Preventing Spread of Infection - The facility will require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice. The facility will require staff to [NAME] (put on) and Doff (take off) PPE before and after contact with resident who needs isolation to prevent the spread of infection to others in the facility.Linens - Personnel will handle, store, process and transport linens so as to prevent spread of infection.

Based on interviews and record review, the facility failed to conduct and document a facility-wide assessment to determine what resources were necessary to care for its residents competently during both day-to-day operations and emergencies for 1 of 1 facility reviewed for facility assessment. The facility failed to complete facility assessment dated [DATE] leaving nurse staff section blank. This failure could place residents at risk of inadequate care or treatment and a decreased quality of life.Findings included: Record review of facility assessment dated [DATE] revealed an incomplete facility assessment at which the facility reported to be using to staff the facility. The Nurse staffing section of the facility assessment had blanks left open for which the facility Administrator should have listed the number of licensed nurses and certified nurse aided on duty for the day shift 6 a.m. - 6 p.m. and night shift 6 a.m. - 6 p.m. based on the facility census and acuity of care needs. During an interview on 06/25/2026 at 12:30 p.m., the Administrator stated that she had been working at the facility for 2 weeks and had not updated the facility assessment. The Administrator stated that it would have been the responsibility of the Administrator to complete and update the facility assessment according to census. The Administrator stated that she had not had time to update the facility assessment, but she had a copy of what was previously used prior dated 12/31/2025. The Administrator stated that it was incomplete with the nurse staffing portion left blank. The Administrator stated that she would get with her RCN to complete an updated facility assessment as of date of survey, 06/25/2026. During an interview on 06/25/2026 at 1:30 p.m., the RCN stated that a completed facility assessment was provided after surveyor intervention. RCN stated that she expected the Administrator to keep the facility assessment up to date in accordance with facility census. RCN stated that residents were at risk of not receiving timely care, but she did not believe quality of care was affected. RCN stated that they did not have a facility assessment policy that they follow.

Based on observation, interview, and record review the facility failed to post the daily nurse staffing information with the current date, resident census, and numbers of staff's actual hours worked at the beginning of each shift for 1 of 1 facility reviewed for nurse staffing. The facility failed to update and post the daily nurse staffing information on 06/25/2026. This failure could affect residents, their families, and facility visitors by placing them at risk of not having access to information regarding the numbers of staff caring for the residents each shift and the facility census.Findings Included: During an interview and record review on 06/25/2026 at 9:20 a.m., the facility's daily nurse staffing posting for current shift had not been completed. The Administrator was unable to produce evidence that the required daily nurse staffing information had been posted at the beginning of the shift. Review of the staffing schedule and staffing assignment sheet identified the license and unlicensed nursing staff working the shift; however, this information was not posted in a readily accessible location for residents and visitors as required. During an observation 06/25/2026 at 9:24 a.m., no daily nurse staffing posted or evidence it had been completed. During an interview 06/25/2026 at 9:25 a.m., the Administrator revealed that the daily nurse staffing was supposed to be posted on the front desk but was not. The Administrator stated that it was the DON's responsibility, however, the DON was no longer employed at the facility and she was unsure who was responsible at the time. The Administrator stated daily staffing was supposed to be posted every day to show the number of nursing staff on duty for the 24-hour day. The Administrator stated that residents and all other people who enter the facility were at risk of not knowing the adequate staffing. During an interview on 06/25/2026 at 9:30 a.m., the MDS nurse stated that she was unsure where the daily nurse staffing was. The MDS nurse stated that DON was responsible for posting the daily staffing. The MDS nurse stated that she was unsure when it was last posted due to the DON leaving the week prior. During an interview on 06/25/2026 at 10:30 a.m., the RCN stated that she expected daily nurse staffing to be posted and placed on the front desk every day for the 24-hour period. The RCN stated that daily nurse staffing was supposed to be posted so that all staff, visitors and residents are aware of the staff numbers that were supposed to be working. The RCN stated that the facility did not have a policy regarding daily nurse staff posting. During an interview on 06/25/2026 at 10:35 a.m., the RN A stated she was unsure who posted daily nurse staffing and was unsure the last time it was posted. The RN A stated that the DON left on Friday and was no longer working for the facility. The RN A stated that staff were at risk of being put in a unsafe situation working.

Based on observation, interview, and record review, the facility failed to ensure residents were free of any significant medication errors for 1 of 11 residents (Resident #1) reviewed for medication errors. The facility failed to ensure Resident #1's hospital discharge orders were implemented to include enoxaparin (a medication commonly known as Lovenox, an anticoagulant medication used to prevent and treat DVT (deep vein thrombosis, a serious condition where a blood clot forms in a deep vein, usually in the legs, causing pain, swelling and redness) and pulmonary embolism (a life-threatening condition that occurs when a blood clot blocks an artery of the lung) after surgery or in patients with limited mobility), cefuroxime (an antibiotic medication commonly known as Ceftin used to treat infections) and Vitamin D3 (a vitamin medication also known as cholecalciferol essential for strong bones, immune function and calcium absorption) daily after her readmission on [DATE]. The facility failed to obtain the discharge medication record and caused to resident to miss approximately five days of enoxaparin, cefuroxime, and Vitamin D3 after her hospitalization in which she received treatment for a tibia / fibula (lower leg bones) fracture that required surgical intervention. This failure was identified by the surveyor during investigation and had not been previously recognized by the facility. An Immediate Jeopardy (IJ) was identified on 04/17/2026 at 12:20 p.m. The IJ template was provided to the facility on [DATE] at 1:00 p.m. While the IJ was removed on 04/17/2026 at 3:13 p.m., the facility remained out of compliance at a potential for more than minimal harm and a severity of pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents who require medication administered by the facility at risk of not receiving their medications as ordered, illness, hospitalizations, exacerbation of their disease processes, and death. Findings included: Record review of Resident #1's EMR accessed 04/17/26, reflected Resident #1 re-admitted to this facility on 04/11/2026 after hospitalization due to a left tibia (shin bone) and fibula (a non-weight-bearing bone located on the outside of the lower leg) closed fracture with surgical intervention. Diagnoses included osteopenia (a condition of reduced bone mineral density that makes bones weaker than average), anemia (a shortage of healthy red blood cells, reducing oxygen delivery to the organs), atherosclerotic heart disease (a condition of plaque build-up that reduces blood flow to the heart), dementia (a progressive syndrome causing cognitive decline to include memory loss, poor judgment and communication issues), and Diabetes Type II (a chronic condition where the body resists insulin or fails to produce enough insulin causing high blood sugar). Record review of Resident #1's Quarterly MDS dated [DATE] revealed she was rarely understood and rarely understood others and was unable to complete the BIMS assessment. Staff assessment of Resident #1's cognitive skills revealed severe impairment. Further review of this MDS revealed Resident #1 had upper and lower extremity range of motion impairment, required a Geri-chair (a specialized reclining, wheeled medical chair for patients with limited mobility), required total assistance in eating, toileting, bathing, required maximum assistance in dressing, bed mobility, transfers. Record review of Resident #1's hospital documents titled Discharge Summary and dated 04/11/2026 indicated under the Medication List, that Resident #1 should start (writing in capital letters) taking these medications: Cefuroxime 500 MG tablet, take 1 tablet (500mg total) by mouth 2 (two) times daily for 5 daysEnoxaparin 40MG/).4ML syringe, Inject 0.4mLs (40 mg total) into the skin daily for 28 days. Start taking on: 04/12/2026Vitamin D3 1000 units caps, take 5000 Units by mouth daily. Start taking on: 04/12/2026. Record review of Resident #1's MAR dated 04/01/2026-04/30/2026 revealed resident was not started on enoxaparin/Lovenox 40MG/0.4ML daily, cefuroxime/Ceftin 500MG twice a day or Vitamin D3 5000 units daily as ordered in hospital discharge. During an observation and interview on 04/16/2026 at 10:28 a.m., Resident #1 was seated in a Geri-chair in a reclined position in the common area near the nurse's station and was clean, odor free and appropriately dressed. Resident was pleasantly confused and responses to direct questions were nonsensical. No signs of distress, pain or discomfort noted. Resident #1 was moved to a secluded location to allow for physical assessment of left lower leg surgical site and upper body for signs of bleeding, bruising, warmth, redness, tenderness or swelling to rule out concern for infection and / or deep vein thrombosis (DVT). No adverse findings were identified. Surgical site was clean, dry, intact and 1 healing bruise to left temple identified from a previous incident when resident hit her head. During an interview on 04/17/26 at 9:25 a.m., the Medical Records technician stated that she normally picks up records after the Monday-Friday clinical meeting to include hospital clinical records with discharge documents and then proceeds to upload them to the EMR system. The Medical Records technician stated she uploaded all of the hospital discharge records that were provided, and the discharge medication list was not in the packet. During an interview on 04/17/26 at 10:19 a.m., ADON A stated that she was on duty when Resident #1 arrived via ambulance stretcher to the facility on [DATE]. ADON A stated that she was not provided with a discharge medication reconciliation form and proceeded to follow the discharge summary which did not identify any medication recommendations. ADON A stated she should have contacted the hospital to request a discharge medication list to complete the admission for Resident #1. The ADON stated that failure to follow the discharge instructions placed Resident #1 at risk for post-operative infection and development of a DVT. The ADON reviewed the facility process for admissions / readmissions was to review and verify the discharge medications with the accepting physician, complete data in-put into the EMR and order new medications as indicated. ADON A stated the admitting orders are reviewed the following day by herself, the other ADON or the DON for accuracy and completeness. The ADON could not say why Resident #1's medications were not reviewed post admission. During an interview on 04/17/2026 at 10:23 a.m., the Physician stated he was notified by the DON on 04/16/2026 (unknown time) that the hospital discharge instructions were not followed for Resident #1. The Physician stated that he provided orders for the facility to start the missed medications on 04/17/2026 and stated the risks for not receiving the ordered medications post-operative would be increased risk for infection and increased risk for development of a DVT The Physician stated that Resident #1 had been assessed since readmission with no adverse effects related to not receiving the medications. The Physician stated that he expects the admitting nurse to notify him of accurate physicians orders when a resident admits or readmits to the facility to ensure appropriate care and treatment. During an interview on 04/17/2026 at 10:53 a.m., RN B stated that when a new or readmission arrives to the facility, she reviews the discharge documents to include the discharge medication list. RN B stated that if the resident arrives to the facility without a discharge medication list, she would contact the hospital to have it faxed to the facility, verify orders with the accepting physicians and order new medications as indicated. RN B stated she did not complete the readmission for Resident #1 and only saw the discharge clinical records that were uploaded to the EMR. During an interview on 04/17/2026 at 10:56 a.m., RN C stated she reviews all new orders with the accepting physician and completes data input for any changes in the EMR. RN C stated if the resident arrives without a medication list, she will contact the hospital to have it faxed over. RN C stated she did not completed the readmission process for Resident #1 and she is not on her unit, so she would have had no need to review the clinical records. During an interview on 04/17/2026 at 10:58 a.m., ADON D stated that she reviews all hospital discharge documents to include discharge medication lists for all new and readmissions with the physician to verify the orders. ADON D stated if a resident arrives to the facility without a discharge medication list, she will check in the EMR to see if it is uploaded or contact the discharging facility to request the record be faxed to the nursing facility. ADON D reviewed the admission process and provided demonstration of the process with a readmission who admitted on [DATE] to include review of the admission orders, verification that the orders were accurately processed in the EMR and that the orders were placed in the medical records box to be uploaded to the EMR. ADON D stated she did not complete the readmission for Resident #1 and began reviewing the clinical documents that were uploaded to the EMR on 4/16/26 after the DON had indicated that not all the orders were transcribed correctly. During an interview on 04/17/2026 at 11:00 a.m., the Administrator stated that she expected the nursing staff to be thorough in the documentation of all new admissions and readmissions and that the DON was ultimately responsible for this area. The Administrator acknowledged that failure to accurately review the medications could result in harm or injury to the resident. During an interview on 04/17/2026 at 3:15 p.m., the DON confirmed the admission process was to review the admitting orders the following day or on the following Monday if the admission occurred on a weekend. The DON could not say why Resident #1's admitting orders were not reviewed per facility protocol. The DON stated that not following discharge instructions placed this resident at risk for increased bleeding / bruising and/or DVT development as well as increased the risk for post-operative infection. Record review of the facility policy titled Admission/Readmission, undated, revealed Procedure: 2. Review the medical diagnoses and physician orders. Orders should include.orders for medications.as specified by the physician. This was determined to be an Immediate Jeopardy (IJ) pattern on 04/17/2026 at 12:20 p.m. The Administrator and Director of Nurses were notified and provided the IJ Template on 04/17/2026 at 1:00 p.m. and a Plan of Removal was requested. The facility's plan of removal was accepted on 04/17/2026 at 3:13 p.m. and included the following: Alleged Issues:The facility failed to ensure Resident #1 was free from significant medication errors when the facility failed to administer anticoagulant medication enoxaparin/Lovenox, antibiotic medication cefuroxime/Ceftin and vitamin supplement medication Vitamin D3 according to the hospital discharge instructions as ordered by the discharging physician. Plan of Removal: 1.Immediate Corrective ActionsThe physician was notified by the DON on 04/17/2026 of the Immediate Jeopardy. The physician gave verbal orders to start the medications that were indicated on the discharge instructions. The DON and Regional Compliance Nurse (RCN) reviewed admissions / readmissions for the 30 days prior to the incident for any other potentially affected residents with completion of 04/17/26. The DON indicated that per facility protocol, the DON/ADON or designee will review all admissions and readmissions for accurate and complete order entry. 2. EducationThe RCN provided 1:1 in-service to the Administrator, DON and ADON's on the following topics: Abuse & Neglect Policy - Failure to transcribe orders or administer medications could be considered NeglectNotification of change in condition policy - Notify Physician immediately of any missed or omitted medications and of the changes in resident condition related to these failures. Medication Reconciliation Policy - The Charge Nurse is responsible to reconcile medications with the physician on admission or readmission. Following physician's orders - The Charge Nurse is responsible to transcribe and initiate all orders for new admissions and readmissions. Nursing staff (22 of 22) were in-serviced on 04/17/2026 by the RCN / DON / ADON regarding the following topics: Abuse & Neglect Policy - Failure to transcribe orders or administer medications could be considered NeglectNotification of change in condition policy - Notify Physician immediately of any missed or omitted medications and of the changes in resident condition related to these failures. Medication Reconciliation Policy - The Charge Nurse is responsible to reconcile medications with the physician on admission or readmission and if no orders are received from the discharging facility, the Charge Nurse is required to contact the discharging facility to obtain orders or the accepting physician if unable to obtain discharge orders. Following physician's orders - The Charge Nurse is responsible to transcribe and initiate all orders for new admissions and readmissions. 3.MonitoringA Physician orders / New admission/readmission monitoring form was initiated on 04/17/2026 at 11:00 a.m. Monitoring for compliance will continue for 6 weeks and be reviewed monthly in QAPI meeting for 90 days. The DON / ADON or designee will monitor each new admissions physicians orders daily Monday - Friday. A weekend supervisor or designee (the facility does not currently have a dedicated weekend supervisor) will monitor the physicians orders on Saturday and Sunday to ensure orders were transcribed correctly per discharge instructions. The Administrator will ensure the clinical meeting IDT members review the physician's orders for all new and readmissions at the clinical meeting Monday-Friday and review the effectiveness of this system at the monthly QAPI meeting. The RCN verified an off-schedule QAPI meeting was held with Performance Improvement Plan in place in conjunction with this Plan of Removal. The surveyor confirmed the POR had been implemented sufficiently to remove the IJ by: During an interview on 04/17/2026 at 10:23 a.m., the Physician confirmed that he had been notified by the DON of the medication error for Resident #1 as well as facility monitoring to ensure no other residents would be affected by similar errors. Record review of Resident #1's physicians orders on 4/17/26 at 1:18 p.m. revealed the attending physician had been contacted and orders were obtained to reconcile Resident #1's medications to reflect the hospital discharge medication list. Record review of Resident #1's April MAR reflected orders for enoxaparin 40MG/4ML was received 04/16/2026 and administered 04/17/2026, Ceftin 500 mg x 5 days BID with first dose administered 04/16/2026, and Vit D3 1000u daily with first dose administered 04/17/2026. Record review on 4/17/26 at 1:25 p.m. revealed that the facility held a QA meeting to review findings of significant medication error and provided surveyor with monitoring sheet implemented to ensure accurate review of medications transcribed for new admissions or readmissions for 6 weeks, then monthly review at QAPI meeting and to be available for the Administrator to review at daily clinical meetings and with spot check. Record review of Inservices completed 04/16/2026 at 1:30 p.m. revealed the RCN provided 1:1 training for the DON and the Administrator that addressed Abuse & Neglect Policy, notification of change in condition, medication reconciliation, and following physicians 'orders. Record review of Inservices completed 04/16/26-04/17/26 at 1:30 p.m. revealed the DON provided training for 9 of 9 administrative and floor nursing staff and that addressed Abuse & Neglect Policy, notification of change in condition, medication reconciliation, and following physicians' orders. Record review of Inservices completed 04/17/2026 at 2:25 p.m. revealed 18 of 18 nursing staff received the Inservice training via automated application (a program that sends the required trainings directly to a cell number or email as designated upon hire) beginning on 04/17/2026 at 8:18 a.m. and completed at 04/17/2026 at 2:15 p.m. to include Abuse & Neglect Policy, notification of change in condition policy, medication reconciliation policy, and following physicians orders. During an interview on 04/17/2026 at 1:19 p.m., ADON A revealed she had been provided training by the DON on the proper procedures to be followed for all new admissions and readmissions specifically related to medication reconciliation to include verifying the orders with the accepting physician, entering the orders in the EMR and ordering medications as needed. During an interview on 04/17/2026 at 1:24 p.m., RN B stated she had received training from the DON on the procedures for new admissions and readmissions, noting that this was a refresher for her as she was already aware of the steps to take to include review of the hospital clinical records, contacting the hospital if the resident arrived without a discharge medication listing, verifying the orders with the physician, entering the orders in the EMR and ordering the medications as needed. During an interview on 04/17/2026 at 1:28 p.m., RN C stated she had received additional training for new admissions and readmissions and understood the content of the training with no concerns. RN C stated she understood the importance of reviewing all clinical documentation provided by the discharging facility, to include the medication list and completing an accurate reconciliation of the medications by notifying the physician, clarifying orders and entering the information in the EMR. During an interview on 04/17/2026 at 1:30 p.m., ADON D stated she had received the training provided by the DON regarding new admissions and readmissions and she was very aware of the steps and processes to ensure accurate medication reconciliation to include verifying the discharge medication orders with the physician or nurse practitioner, entering the orders in the EMR and ordering any new medications. ADON D stated that if a new medication is available from the pharmacy medications provided as house stock, she will administer the first dose and order the remaining doses. During an interview on 04/17/2026 at 1:35 p.m., LVN E and LVN F (MDS Nurses in shared office) confirmed they had received the training and understood the content. LVN E stated she does not usually have to do admissions, but understood it was vital to verify the discharge medications with the physician and notify the discharging facility if the list did not arrive with the resident. LVN F stated that once the medication list if verified with the physician, the nurse would need to enter the orders in the EMR and order the medications. During an interview on 04/17/2026 at 1:40 p.m., LVN G confirmed she had received training on admissions and readmissions regarding medication reconciliation and understood correct process to complete an admission to include reviewing the clinical records, contacting the physician to verify the orders, entering the orders in the EMR and ordering the medications. During an interview on 04/17/2026 at 1:44 p.m., LVN H confirmed she had received training on the admission process and understood content and procedures to be followed to include the importance of reviewing the clinical documents, specifically the medications and to review new orders with the physician. LVN H stated that if a resident arrived to the facility without a discharge medication list, she would notify the discharging facility to request a copy be faxed. During an interview on 04/17/26 at 1:50 p.m., LVN K confirmed she had attended the training and understood the correct processes to be followed when a new admission or readmission arrives to the facility. During an interview on 04/17/2026 at 2:00 p.m., the DON confirmed that she had completed an audit of the past 30 days of admissions and readmissions to ensure accurate medication reconciliation according to the discharge medication listing for 31 of 31 residents. Record review of the admission and Discharge report dated 04/16/2026 and reflecting admissions and readmissions from the period of 03/16/2026-04/16/2026 revealed a total of 31 admissions to include Resident #1. Record review of hospital discharge medication list for 11 of 11 residents admitted in this time period in comparison with the facility MAR for the identified admission date revealed no discrepancies in medication reconciliation with the exception of the identified Resident #1. The RCN, Director of Nurses and Administrator were informed that the Immediate Jeopardy was removed on 04/17/2026 at 3:13 p.m. The facility remained out of compliance at a potential for more than minimal harm with a scope identified as pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene were provided for 1 of 5 (Resident #1) residents reviewed for ADLs. The facility failed to ensure Resident #1 received his scheduled showers in February 2026. These failures could place residents at risk of not receiving services/care, decreased hygiene and decreased quality of life.Findings Include: 1. Record review of the face sheet dated 3/5/36 indicated Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including vascular dementia (progressive decline in thinking, memory, and behavior caused by impaired blood flow to the brain), hypertension (elevated blood pressure), major depressive disorder ((a serious, common mood disorder characterized by persistent sadness, loss of interest in activities, and fatigue), and chronic kidney disease stage 3 (kidney disease with mild to moderate damage and kidneys are less able to filter water and flood out of your blood). Record review of the MDS dated [DATE] indicated Resident #1 was understood by others and understood others. The MDS indicated Resident #1 had a BIMS score of 13 and was cognitively intact. The MDS indicated Resident #1 did not reject care. The MDS indicated Resident #1 required supervision or touching assistance with bathing. Record review of the care plan last revised on 2/26/26 indicated Resident #1 had an ADL self-care performance deficit with interventions including supervise as needed with bathing.Record review of Resident #1's Documentation Survey Reports dated February 2026 indicated Resident #1 was scheduled for showers Mondays, Wednesdays, and Fridays. The Documentation Survey Report indicated:Resident #1 was scheduled for 12 showers/baths and did not receive 7 of her scheduled showers.Resident #1 did not receive a shower on 2/9/26, 2/11/26, 2/13/26, 2/16/25, 2/20/26, 2/23/26, 2/25/26, and 2/27/26.Scheduled Bathing was not applicable on 2/4/26 and 2/6/26. Record review of Resident #1's EMR indicated there were no shower refusal sheets for February 2026. During an interview on 3/5/26 at 8:50 a.m. Resident #1 said she really did not remember if she had not gotten showers over the past 2 months. Resident #1 did not get her shower on 3/4/26 because she was not feeling good and chose not to take it. Resident #1 said staff do not come to get her for showers. Resident #1 said if she wanted a shower, she had to pursue it getting done. Resident #1 said she did not refuse showers. Resident #1 said when she did not get her scheduled showers, she felt yucky. During an interview on 3/5/26 at 12:39 p.m. CNA A said she worked as a shower aide in the facility Monday through Friday on the 6:00 a.m.- 2:00 p.m. shift. CNA A said if there were a blank space on the Documentation Survey Report for a scheduled shower it would indicate the shower was not done. CNA A said she did not know what it meant if the Documentation Survey Report indicated a shower was not applicable. CNA A said residents received their showers every other day. CNA A said Resident #1 would refuse her showers at times due to not wanting to get up. CNA A said if a resident refused a shower she completed and turned in a shower refusal sheet. CNA A said refusals of showers should also be documented in the Documentation Survey Report. CNA A said the importance of the residents receiving their scheduled showers was for hygiene, wound care, and to prevent a decline in health. During an interview on 3/5/26 at 12:45 p.m. the DON said the facility did have shower refusal sheets. The DON said she had checked the refusal sheets that had not been uploaded into the EMR and that Resident #1 did not have any refusal sheets that had not been uploaded into the EMR. During an interview on 3/5/26 at 2:03 p.m. the DON said if there was a blank on the Documentation Survey Report where a shower/bath was scheduled it indicated the shower was not done. The DON said she was not sure what not applicable meant in the Documentation Survey Report where a shower/bath was scheduled but assumed it was documented not applicable because the shower/bath was not done. The DON said she expected residents to receive their showers 3 times a week. The DON said she expected shower/bath refusals to be documented in the progress notes if a resident refused their shower/bath more than 2 times in one week. The DON said the importance of residents receiving their scheduled showers was cleanliness, hygiene, and to make the residents feel better. Record review of the facility's undated Bath, Tub/Shower policy indicated, Bathing by tub bath or shower is done to remove soil, dead epithelial cells (a thin, continuous, protective layer of cells), microorganisms (tiny, often single-celled organisms-including bacteria, viruses, and fungi), and body odor to promote comfort, cleanliness, circulation, and relaxation.The aging skin becomes dry, wrinkled, thinner, and blemished with various aging spots over time and is easily affected by environmental temperatures and humidity sun exposure soaps, and clothing fabrics. The frequency and type of bath or shower is preferred and necessary for some, the aging skin can be maintained by bathing every two days or with partial bathing as needed.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 staff (Treatment Nurse) and 1 of 7 residents (Resident #2) observed for infection control. The facility failed to ensure the Treatment Nurse wore a gown when providing wound care to Resident #2. This failure could place residents and staff at risk for MDROs, cross-contamination, spread of infection and could potentially affect all others in the building.Findings Include: 1. During an observation on 3/3/26 at 1:32 p.m. the Treatment Nurse performed wound care on Resident #2. EBP signage and PPE observed outside Resident #2's room with a sign in red that indicated personal care gown and gloves. The Treatment Nurse knocked on Resident #2's door before entering room. The Treatment Nurse assessed Resident #2's pain prior to performing wound care. The Treatment Nurse washed her hands and put on clean gloves. The Treatment Nurse did not put on a gown. Treatment Nurse removed the dressing to Resident #2's back, removed gloves, performed hand hygiene, and put on clean gloves. The Treatment Nurse cleansed the wound per physician orders, removed gloves, performed hand hygiene, put on clean gloves. The Treatment Nurse applied calcium alginate with silver (a highly absorbent, antimicrobial, and comfortable wound dressing designed for moderate to heavy, infected or colonized (contains multiple bacteria on the surface without causing an active immune response, clinical symptoms, or delayed healing)) and foam, boarded dressing (an absorbent, self-adherent wound dressing with a surrounding adhesive edge) to the wound, removed gloves, performed hand hygiene, and put on clean gloves. Treatment Nurse disposed of all supplies and dirty dressing in biohazard bag, removed gloves, washed hands, and exited the Resident #2's room. During an interview on 3/3/26 at 2:10 p.m. the Treatment Nurse said EBP stood for enhanced barrier precautions and included wearing a gown and gloves when providing care. The Treatment Nurse said gown and gloves should be worn when providing wound care to an open wound and when providing urinary catheter (a flexible tube inserted into the bladder to drain urine when a person cannot urinate naturally) or colostomy (a surgical procedure that creates an opening in the abdomen, connecting the colon to the outside of the body to divert waste into a pouch) care. The Treatment Nurse said she forgot to put on a gown prior to performing wound care because she was concerned with Resident #2's pain and was not paying attention. The Treatment Nurse said she usually wears a gown and gloves when performing wound care. The Treatment Nurse said the importance of EBP was to prevent cross contamination, to prevent spread of bacteria, and for infection control. During an interview on 3/5/26 at 1:52 p.m. the DON said when a resident was on EBP she expected staff to wear a gown, gloves, and mask or face shield (if necessary to protect the face from bodily fluids) when providing direct care to protect the residents from cross contamination. The DON said EBP was necessary for residents with open wounds, urinary catheters, PICC lines (a long, thin, flexible tube inserted into a large upper arm vein and thread toward the heart for long-term intravenous access), and PEG tubes (a flexible feeding tube inserted through the abdomen into the stomach using an endoscope to provide long-term nutrition, hydration, or medication to residents with swallowing difficulties or severe nutritional deficits). Record review of the facility's undated Enhanced Barrier Precautions indicated, Multidrug-resistant organism (MDRO) transmission is common in long-term care (LTC) facilities. Many residents in nursing homes are at increased risk of becoming colonized and developing infections with MDRO's. Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities. EBP are used in conjunction with standard precautions and expand the use of PPE to donning (putting on) of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 6 residents (Resident #1 and Resident #2) reviewed for infection control. The facility failed to ensure CNA B and CNA C performed hand hygiene while providing incontinent care for Resident #1 on 11/24/25. The facility failed to have Personal Protective Equipment, also known as PPE, ( specialized clothing or equipment worn to protect individuals from hazards in various settings, such as the workplace, and includes items like gloves, safety helmets, masks, and eye protection) outside Resident #1's and Resident #2's rooms, who required EBP (an infection control strategy that uses gowns and gloves during high-contact care activities to reduce the transmission of multidrug-resistant organisms (MDROs) on 11/24/25. This failure could place residents at risk for cross-contamination and the spread of infection.Finding included:Record review of Resident #1's face sheet, dated 11/24/25, revealed an [AGE] year-old female, admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses to include chronic obstructive pulmonary disease, also called COPD ( a progressive lung disease that causes restricted airflow and breathing problems), coronary artery disease, also known as CAD, (a condition where plaque buildup narrows or blocks the coronary arteries, which supply oxygen-rich blood to the heart), and diabetes (high blood sugars).Record review of Resident #1's annual MDS assessment, dated 10/09/25, indicated Resident #1 usually understood and was understood by others. Resident #1's BIMS score was 12, which indicated her cognition was moderately impaired. The MDS indicated Resident #1 required assistance with toileting, bed mobility, dressing, personal hygiene, transfers, and eating. The MDS indicated she was always incontinent of bowel and bladder.Record review of Resident #1's comprehensive care plan, revised on 11/04/25, indicated Resident #1 had EPB and an indwelling catheter. The interventions required staff to wear gloves and a gown when the following activities occurred: linen change, resident hygiene, transfer, dressing, toileting/incontinent care, bed mobility, wound care, enteral feeding care, catheter care, trach care, bathing, or other high-contact activity. Also, there should be a posting at the residents' room entrance indicating that the residents were on EBP.Record review of Resident #1's physician order, dated 11/12/25, indicated urinary catheter 16 Fr 10cc bulb to gravity drainage ( urine flows from the bladder into a drainage bag solely through the force of gravity) every shift for gross hematuria (the presence of blood in the urine that is visible to the naked eye, causing the urine to appear pink, red, or brown).Record review of Resident #1's physician order, dated 11/19/25, indicated enhanced barrier precautions.During an observation and interview on 11/24/25 at 10:45 a.m., Resident #1 did not have an EBP sign on the door. Resident #1 had an indwelling catheter. She said staff did not wear gowns when they provided incontinent care.During an observation on 11/24/25 at 3:59 p.m., CNA B and CNA C provided incontinence care for bowel and indwelling catheter care for Resident #1. CNA B wiped Resident #1's right buttock, which contained bowel, and then assisted to turn her on her left side without hand hygiene or changing her gloves. CNA C wiped Resident #1's left side buttock, which contained bowel, and assisted in turning Resident #1 to her back without hand hygiene or changing her gloves. CNA B wiped her front area using the same wipe and wiping side to side, then used the same wipe and wiped her indwelling catheter without changing her gloves or performing hand hygiene. CNA B then grabbed a clean brief, applied barrier cream, and changed her linen, all while using the same dirty gloves. During an interview on 11/24/25 at 4:22 p.m., CNA B and CNA C said Resident #1 did not have an EBP sign on her door or a cart outside her door. They said they had not been using gowns while providing care for Resident #1. They said LVN A gave them the gowns today (11/24/25) when they told her the surveyor wanted to watch incontinent care. CNA B and CNA C said they did not perform hand hygiene or change their gloves after wiping Resident #1, then touching the clean brief and linen with dirty gloves. They said they knew that without hand hygiene or removing dirty gloves, they could cause cross-contamination and infection.During an interview on 11/24/25 at 5:00 p.m., LVN A said she was Resident #1's nurse. She said she expected staff to provide incontinent care to keep the residents clean. She said she expected the CNAs to practice hand hygiene and change gloves when soiled. She said Resident #1 was on EBP. She said Resident #1 did not have signage or a cart placed on her door or outside her room, and said it was an oversight. She said if staff were not wearing proper PPE (gown and gloves), it could cause infection and or bacteria. She said when the CNAs told her they were going to provide incontinent care, she saw that Resident #1 did not have a cart or a sign on her door, so she gave them gowns to use. She said afterwards she told management about the signage and cart for Resident #1. 2. Record review of Resident #2's face sheet, dated 11/24/25, indicated she was a [AGE] year-old female admitted on [DATE] with diagnoses which included compression fracture of thoracic (back) at #7 and #8 vertebrae, chronic obstructive pulmonary disease, also called COPD ( a progressive lung disease that causes restricted airflow and breathing problems), and diabetes (a chronic disease where the body doesn't produce enough insulin or cannot effectively use the insulin it produces, leading to high blood sugar levels).Record review of Resident #2's admission MDS assessment, dated 10/15/25, indicated Resident #2 usually understood and was usually understood by others. Resident #2 had moderately impaired daily decision-making. The MDS indicated Resident #2 required maximum assistance with her ADLs. The MDS indicated Resident #2 was always incontinent of bowel and had an indwelling catheter. Record review of Resident #2's physician order, dated 10/03/25, indicated a urinary catheter 18Fr/30cc to gravity drainage every shift for pain. Record review of Resident #2's comprehensive care plan, dated 10/03/25, indicated Resident #1 had enhanced barrier precautions and an indwelling catheter. The interventions required staff to wear gloves and a gown when the following activities occurred: linen change, resident hygiene, transfer, dressing, toileting/incontinent care, bed mobility, wound care, enteral feeding care, catheter care, trach care, bathing, or other high-contact activities. Also, there should be a posting at the residents' room entrance indicating that the residents were on EBP.During an observation and interview on 11/24/25 at 11:35 a.m., Resident #2 was lying in her bed. Resident #2 had an indwelling catheter but did not have an EBP posting or a cart outside her door or on the hallway. Resident #2 was unable to answer whether the staff were wearing PPE while providing care. During an interview on 11/24/25 at 4:00 p.m., CNA E said she was Resident #2's aide. She said she was not aware that Resident #2 required PPE when providing care. She said they usually placed a sign on the door and a cart outside her room, but because they had not, she did not wear PPE (gown). She said it placed her and the resident at risk of infection.During an interview on 11/24/25 at 4:15 p.m., LVN D said she was Resident #2's charge nurse. She said she was aware Resident #2 was on EBP but said she did not have signage or a cart outside her room, which could cause staff not to wear PPE (gown and gloves) when providing care. She said that without the proper PPE, it could cause an infection for the residents. She said Resident #2 should have had signage on her door and a cart by her door when she was admitted , but for unknown reasons, she did not. She said she did not think about the signage or cart not being there until questioned by the state surveyor. She said someone from management placed the signage on the door and a cart outside Resident #2's room about thirty minutes ago. During an interview on 11/24/25 at 5:55 p.m., the DON said she had worked at the facility for about three weeks. She said she expected the CNAs to perform incontinent care correctly. She said she expected staff to change their gloves between dirty to clean and use hand hygiene between glove changes. She said the IP nurse oversaw the infection control process. She said she was not aware that Resident #1 or Resident #2 did not have a sign on their door or a cart outside of their room. She said staff should change gloves, practice hand hygiene and wear proper PPE (gown and gloves) when caring for residents on EBP to prevent infection and cross-contamination.During an interview on 11/24/25 at 6:00 p.m., the IP nurse said she was responsible for the infection process. She said when a resident was admitted or received a new order for EBP, she was responsible for making sure the resident had a sign on their door and a cart outside their door. She also said anyone who saw that they did not have the signage or cart could have placed it on or by the residents' room. She said she reviewed orders and did random audits and rounds to ensure signage and carts were in place. She said she was not aware that Resident #1 and Resident #2 did not have signs or carts outside their rooms, but knew they were both on EBP. She said sometimes the signs fall. She said if staff were unaware of EBP, then they could spread infection.During an interview on 11/24/25 at 6:09 p.m., the interim Administrator said she expected all staff to use proper hand hygiene techniques between dirty and clean areas with all care. The Administrator said the DON and IP nurse were responsible for ensuring staff were trained on incontinent care, hand washing, EPB, and infection control. She said improper hand hygiene and not wearing the proper PPE (gown and gloves) could place residents at risk for cross-contamination or infection.Record review of the facility's policy titled Fundamentals of Infection Control Precautions, undated, indicated, A variety of infection control measures are used to decrease the risk of transmission of microorganisms in the facility. These measures make up the fundamentals of infection control precautions. 1. Hand Hygiene: Hand hygiene continues to be the primary means of preventing the transmission of infection. Record review of the facility's policy titled Infection Control Plan, dated 03/24, indicated, Infection Control: The facility will establish and maintain an Infection Control Program designed to provide a safe, sanitary, andcomfortable environment and to help prevent the development and transmission of disease and infection. Intent: The intent of this policy is to ensure that the facility develops, implements, and maintains an Infection Prevention and Control Program in order to prevent, recognize, and control, to the extent possible, the onset and spread of infection within the facility. The program will: Perform surveillance and investigation to prevent, to the extent possible, the onset and the spread of infection; Prevent and control outbreaks and cross-contamination using transmission-based precautions in addition to standard precautions.Record review of the facility's policy titled Nursing: Personal Care, dated 05/11/22, indicated, Purpose: This procedure aims to maintain the resident's dignity and self-worth and reduce embarrassment by providing cleanliness and comfort to the resident, preventing infections and skin irritation, and observing the resident's skin condition. #17) Gently perform perineal care, wiping from clean, urethral area, to dirty/' rectal area, to avoid contaminating the urethral area -CLEAN to DIRTY! Female resident: Working from front to back, wipe one side of the labia majora1 the outside folds of the perineum (skin that protects the urinary meatus and the vaginal opening). Continue perineum care to the inner thigh. If applicable, gently wash the juncture of the Foley catheter tubing from the urethra down the catheter about three inches. Then wipe the other side. Use a clean area of the washcloth or pre-moistened cleansing wipes for each stroke.Record review of the facility's policy titled Enhanced Barrier Precautions, undated, indicated, Multidrug-resistant organism ([NAME]) transmission is common in long-term care (LTC) facilities. Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing.EBP are indicated for residents with any of the following: Wounds and/or indwelling medical devices (Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies) even if the resident is not known to be infected or colonized with a [NAME]. The facility will ensure PPE and alcohol-based hand rub are readily accessible to staff prior to entry to their room. Communication to Staff: The facility will utilize posting outside the room to communicate to staff if a resident requires EBP.

Based on observations, interviews and recorded reviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in the facility's only kitchen. The facility failed to ensure foods stored in the 1 of 1 refrigerator were removed by the use by date. The failure could place residents at risk for food-borne illnesses and food contamination. Findings included: Observation on 08/12/2025 at 8:48 AM revealed in the facility's only walk-in refrigerator there were two bags of spinach with a use by date of 07/23/2025 stored on the top shelf. The contents of the bags were dark green and greenish brown, wet and slimy and had leaked onto the boxes below. Interview on 08/13/2025 at 2:15 PM with the DM revealed she was responsible for checking the items in the cooler for the use by dates and removing those items before they expired. The bags of spinach were items that she inevitably missed. The risk was it could make the residents sick if they consumed food that had expired. Interview on 08/14/2025 at 2:40 PM with the Administrator revealed her expectation was food use by dates should be monitored and kept in compliance with food and storage procedures. The expired food could contaminate something else in the refrigerator or make residents sick. Interview on 08/14/2025 at 3:33 PM with the DON revealed the expectation was food should be consumed by the expiration date or thrown away. If it was consumed it might upset the resident's stomach. Review of Policy Food Storage and Supplies undated, revealed; 8 On perishable foods, microorganisms such as molds, yeast, and bacteria can multiply and cause food to spoil. Spoiled food will develop an off odor, flavor or texture due to naturally occurring spoilage bacteria. If a food has developed such spoilage characteristics, it should not be eaten. Review of the U.S. Public Health Service Food Code, dated 2022, reflected: 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety. (C) A refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD ingredient or a portion of a refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is subsequently combined with additional ingredients or portions of FOOD shall retain the date marking of the earliest prepared or first-prepared ingredient. (D) A date marking system that meets the criteria stated in (A) and (B) of this section may include: (1) Using a method approved by the regulatory authority for refrigerated, ready-to-eat time/temperature control for safety food that is frequently rewrapped, such as lunchmeat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; (2) Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section; (3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section; or (4) Using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the REGULATORY AUTHORITY upon request.

Based on observation, interview, and record review the facility failed to ensure that the resident environment remained free of accident hazards to prevent injuries for 1 of 6 residents (Resident #1) reviewed for accident hazards. The facility failed to ensure CNA A properly transferred Resident #1 via mechanical lift (a device designed to help caregivers transfer patients) on 12/11/224 resulting in Resident #1 having a significant laceration to her scalp with exposure to underlying skull. The noncompliance was identified as PNC. The IJ began on 12/11/24 and ended on 12/11/24. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for injury and death. Findings include: 1. Record review of the face sheet dated 12/13/24 indicated Resident #1 was an [AGE] year-old female, admitted to the facility on [DATE] with diagnoses including Alzheimer's, dementia, dysphagia (difficulty swallowing foods or liquids), and psychotic disorder (a mental disorder characterized by a disconnection from reality). Record review of the MDS dated [DATE] indicated Resident #1 rarely/never understood others and was rarely/never understood by others. The MDS indicated Resident #1 did not have a BIMS score. The MDS indicated Resident #1 was dependent with dressing, personal hygiene, bathing, and transfers. Record review of the care plan dated revised on 11/20/24 indicated Resident #1 had an ADL self-care performance deficit with interventions including requires 2-staff participation with mechanical lift transfers. Record review of the Nurse's Progress note dated 12/11/24 at 6:00 a.m. indicated, CNA getting resident out of bed. had resident in [mechanical lift] and while she was fixing to put resident in Geri-chair (a large, padded chair designed to help people with limited mobility sit and stand comfortable) roommate got up to bathroom all upset because lights were turned on and people talking and wouldn't let her sleep and pushed Geri chair back out of the way when CNA turned to get Geri chair resident leaned over and fell out of [mechanical lift] sling hitting head on side table has laceration to top of head and hematoma to right side of head and hematoma to right index finger. while in room assessing resident roommate continued fussing and complaining to staff. Record review of the Fall assessment dated [DATE] indicated Resident #1 was a high risk for falls. The Fall Assessment indicated Resident #1 had not had any falls in the past three months and was not able to stand. Record review of the hospital records dated 12/11/24 indicated per EMS report, nursing facility staff were attempting to transfer Resident #1 and accidently dropped her. The hospital records indicated Resident #1 hit her head sustaining a significant laceration to her scalp with exposure of underlying skull. The hospital records indicated the laceration was elliptical shaped (an oval shape, similar to a stretched-out circle) and approximately 25 cm in diameter. The hospital records indicated the laceration was large to where underlying skull could be seen. The hospital records indicated there was no deformity or fracture of the skull. The hospital records indicated the laceration was repaired at bedside requiring 22 staples. During an interview on 12/13/24 at 9:18 a.m. the Administrator said CNA A was suspended pending investigation and would probably be termed. The Administrator said she was waiting to hear from corporate regarding their decision on whether to terminate CNA A. Record review of a CNA Proficiency Audit dated 10/1/24 indicated CNA A had been successfully checked off on CNA skills including Hoyer Lift (Mechanical Lift)-2 person assist. During an interview attempt on 12/13/24 at 9:20 a.m. CNA A's phone was not in working service. During an interview attempt and observations on 12/13/24 at 10:45 a.m. Resident #1 did not answer any questions from the surveyor or speak. Resident #1 was observed with a pressure dressing to her head dated 12/12/24. Record review of the facility's undated Hydraulic Lift policy indicated, The hydraulic lift is a mechanical device used to transfer a resident from and to the bed and chair. It is reserved for those who are paralyzed, or too weak to transfer without complete assistance. The number of staff to provide assistance with the transferred should be determined by the manufacturer recommendations. The resident will achieve safe transfer to bed or chair via a mechanical lift device. The caregiver will demonstrate safe and correct transfer of the resident to the bed or chair via the hydraulic lift . Record review of the Battery Operated Electric Total Lift Owner's Manual revised 10/13/20 did not indicated the recommended number of staff to provide assistance with a transfer. The Administrator was notified on 12/13/24 at 12:13 p.m. that a Past Non-Compliance Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on 12/3/24 at 12:17 p.m. The facility had corrected the noncompliance by the following: Suspending CNA A pending investigation. In-servicing staff regarding KARDEX (a nursing filing system that enable nursing staff to write, organize, and easily reference key patient information that shapes their nursing care plan) use in the EMR and Hydraulic Lift Use. Staff checkoffs by the DOR regarding Mechanical Lift Transfers The surveyor confirmed the facility had corrected the non-compliance prior to survey starting by: Record review of the Employee Disciplinary Report dated 12/11/24 indicated CNA was placed on investigatory suspension pending investigation into allegations of a resident injury involving the employee. Staff interviewed (CNA A, CNA B. CNA C, CNA D, Treatment Nurse E, CNA F, LVN G, MA H) on 12/13/24 between 10:00 a.m. and 10:41 a.m. were able to answer all question regarding in-services including mechanical lift transfer should always be performed with 2 staff members, the sling date should be checked to ensure it is not 6 months old or older, the integrity of the sling should be checked, the lift should be checked to ensure it was in proper working order, the wheelchair or bed should be locked, and the lifts base should be opened to the widest possible position, and residents' transfer status should always be checked in the KARDEX prior to transfer. Record review indicated 37 out of 60 direct care staff had received Mechanical Lift Transfer Skills Checkoffs from 12/11/24-12/13/24. During an interview on 12/13/24 at 9:39 a.m. the Administrator said the facility had 100% of staff in-serviced regarding mechanical lift use and KARDEX use in the EMR. The Administrator said staff were required to receive mechanical lift training from the DOR prior to being able to work the floor. The Administrator said the mechanical lift training would be ongoing until all staff had been trained/checked-off. Record review of Resident #1's care plan indicated it was in process of being revised. Record review of the in-service sign-in sheets and the employee roster dated 12/11/24 indicated 100% of nursing staff had been in-serviced regarding mechanical lift use and KARDEX use in the EMR. During an observation on 12/13/24 at 10:20 a.m. CNA B and CNA C performed a mechanical lift transfer. CNA B and CNA C performed mechanical lift transfer with 2 staff members, checked the date of lift pad prior to transfer, ensured sling was in good working order, guided resident while in sling to prevent injury, ensured the base was set to widest position when lifting and lowering resident, ensured the wheelchair wheels were locked prior to lowering resident to chair.

Based on observations, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 2 residents (Resident #1 and Resident #2) reviewed for enhanced barrier precautions and infection control practices with foley catheter care. 1. The facility failed to ensure CNA B and the DON wore enhanced barrier precautions while performing foley catheter care for Resident #1 on 10/23/2024. 2. The facility failed to ensure RN A and CNA C wore enhanced barrier precautions and performed hand hygiene while performing foley catheter care for Resident #2 on 10/23/2024. These failures could place residents and staff at risk for cross contamination and the spread of infection. The findings included: 1. Record review of the face sheet, dated 10/23/24, reflected Resident #1 was a [AGE] year-old male who admitted to the facility on [DATE] with a diagnosis of obstructive and reflux uropathy (when your urine can't flow [either partially or completely] through your ureter, bladder, or urethra due to some type of obstruction and instead flows backward, or refluxes, into your kidneys) and benign prostatic hyperplasia without lower urinary tract symptoms (condition in which the flow of urine is blocked due to the enlargement of prostate gland). Record review of the admission MDS assessment, dated 08/06/2024, reflected Resident #1 had clear speech and was understood by others. The MDS reflected Resident #1 was usually able to understand others. The MDS reflected Resident #1 had a BIMS score of 10, which indicated moderately impaired cognition. The MDS reflected Resident #1 had no behaviors or refusal of care. The MDS reflected Resident #1 had an indwelling catheter. Record review of the comprehensive care plan, revised 07/31/2024, reflected Resident #1 had an indwelling foley catheter. The comprehensive care plan further reflected Resident #1 required the use of enhanced barrier precautions. The interventions included: gloves and gown should be worn during .catheter care . During an observation on 10/23/2024 beginning at 2:51 PM, signage was observed on Resident #1's door that stated EBP steps .perform hand hygiene .wear gown .wear gloves .dispose of gown and gloves in room .Use EBP during high-contact care activities for residents with indwelling medical devices ( .urinary catheter .) . A plastic cart with multiple drawers was located outside the door that held isolation gowns. CNA B and the DON knocked and entered Resident #1's room. CNA B assisted Resident #1 into the bed, pulled down his pants, and provided foley catheter care without applying enhanced barrier precautions. The DON was in the room with CNA B. The DON assisted CNA B with the foley catheter care without applying enhanced barrier precautions. 2. Record review of the face sheet, dated 10/23/2024, reflected Resident #2 was an [AGE] year-old female who admitted to the facility on [DATE] with a diagnosis of neuromuscular dysfunction of the bladder (occurs when a person's nerves, spinal cord, or brain have problems sending electrical signals to the bladder). Record review of the admission MDS assessment, dated 10/13/2024, reflected Resident #2 had clear speech and was usually understood by others. The MDS reflected Resident #2 was usually able to understand others. The MDS reflected Resident #2 had a BIMS score of 11, which indicated moderately impaired cognition. The MDS reflected Resident #2 had no behaviors or refusal of care. The MDS reflected Resident #2 had an indwelling catheter. Record review of the comprehensive care plan, revised on 10/09/2024, reflected Resident #2 had an indwelling foley catheter. The comprehensive care plan further reflected Resident #2 required the use of enhanced barrier precautions. The interventions included: gloves and gown should be worn during .catheter care . During an observation on 10/23/2024 beginning at 3:36 PM, signage was observed on Resident #1's door that stated EBP steps .perform hand hygiene .wear gown .wear gloves .dispose of gown and gloves in room .Use EBP during high-contact care activities for residents with indwelling medical devices ( .urinary catheter .) . A plastic cart with multiple drawers was located outside the door that held isolation gowns. RN A and CNA C knocked and entered Resident #2's room. CNA C and RN A assisted Resident #2 with foley catheter care without applying enhanced barrier precautions. CNA C and RN A did not perform hand hygiene during glove changes while performing foley catheter care on Resident #2. During an interview on 10/23/2024 beginning at 3:49 PM, CNA C stated Resident #2 had signage outside her door for enhanced barrier precautions. CNA C stated she was unsure why Resident #2 required the use of enhanced barrier precautions. CNA C stated most residents were on enhanced barrier precautions because they had wounds, or infections in their urine. CNA C stated she should have asked the nurse why a resident had signage on their door for enhanced barrier precautions. CNA C stated she was provided in-service training on enhanced barrier precautions at the facility. CNA C stated hand hygiene should have been performed during glove changes. CNA C stated she should have used alcohol rub or hand washing before applying new gloves. CNA C stated she just forgot to sanitize her hands before applying new gloves. CNA C stated it was important to ensure enhanced barrier precautions were used and hand hygiene was performed during glove changes to protect herself and the residents from contamination and prevent the spread of infection. During an interview on 10/23/2024 beginning at 3:56 PM, RN A stated enhanced barrier precautions were implemented for residents with a foley catheter or wound. RN A stated she believed enhanced barrier precautions were only used when changing a foley catheter or emptying the urinary drainage bag. RN A was unsure if enhanced barrier precautions were required while performing foley catheter care. RN A stated she was provided training on enhanced barrier precautions when it first became a requirement. RN A stated hand hygiene should have been performed during glove changes. RN A stated she realized they did not have any sanitizer in the room while performing foley catheter care on Resident #2. RN A stated it was important to ensure hand hygiene was performed during glove changes to keep the resident clean and prevent infection. During an interview on 10/23/2024 beginning at 4:06 PM, CNA B stated she realized she had forgotten to apply enhanced barrier precautions while performing foley catheter care on Resident #1. CNA B stated she was nervous and in a hurry. CNA B stated she normally applied enhanced barrier precautions. CNA B stated it was important to ensure enhanced barrier precautions were applied during foley catheter care for infection control purposes. During an interview on 10/23/2024 beginning at 4:11 PM, the DON stated he should have applied enhanced barrier precautions prior to performing foley catheter care on Resident #1. The DON stated he came into the room in a hurry and just forgot to apply the PPE. The DON stated he expected the facility staff to ensure enhanced barrier precautions were used while providing direct care, such as foley catheter care. The DON stated he expected facility staff to ensure hand hygiene was performed during glove changes. The DON stated the infection control preventionist and the nursing management were responsible for monitoring to ensure staff were implementing enhanced barrier precautions. The DON stated the infection preventionist was at home resting because she had to work the night shift. The DON stated it was important to ensure enhanced barrier precautions were used and hand hygiene was performed during glove changes as an extra step to prevent the spread of infection. During an interview on 10/23/2024 beginning at 5:24 PM, the Administrator stated she expected facility staff to ensure enhanced barrier precautions were used and hand hygiene was performed during glove changes. The Administrator stated the IDT were responsible for monitoring to ensure enhanced barrier precautions were used and hand hygiene was performed at appropriate times. The Administrator stated the IDT included the charge nurse, infection preventionist, and the DON. The Administrator stated it was important to ensure enhanced barrier precautions were used and hand hygiene was performed for infection control purposes. Record review of the Catheter Care policy, revised 02/13/2007, did not address hand hygiene or the use of enhanced barrier precautions. Record review of the Fundamentals of Infection Control Precautions policy, updated 03/2023, reflected 1. Hand Hygiene The following is a list of some situation that require hand hygiene .after removing gloves or aprons .

Based on interview and record review, the facility failed to develop and implement a baseline care plan within 48 hours of admission that included the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care for 2 of 7 residents (Resident #1 and Resident #2) reviewed for baseline care plans. The facility failed to ensure Resident #1 had a baseline care plan completed within 48 hours of her admission on 8/26/24 that included the minimum healthcare information necessary to properly care for her including initial goals based on admission orders, physician orders, dietary orders, therapy services, and social services. The facility failed to ensure Resident #2 had a baseline care plan completed within 48 hours of her admission on 8/30/34. This failure could place newly admitted residents at risk of receiving inadequate care and services. Findings included: 1. Record review of the face sheet dated 9/5/24 indicated Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including lung cancer, cancerous neuroendocrine (certain cells that release hormones into the blood in response to stimulation of the nervous system) tumors, alcoholic cirrhosis of the liver (a late stage of alcohol-related liver disease that occurs when the liver is permanently damaged), COPD, and diabetes. Record review of the entry MDS dated [DATE] indicated Resident #1 admitted to the facility from home on 8/26/24. Record review of Resident #1's medical records indicated there was not a baseline care plan. Record review of the comprehensive care plan revised on 8/30/24 indicated Resident #1 had little or no activity involvement related to the resident wishing not to participate initiated on 8/27/24. The care plan indicated all other focuses for Resident #1 were not initiated until 8/30/24. Record review of the Baseline Care Plan Acknowledgement dated 8/29/24 indicated Resident #1 and her representative had been provided a copy of the baseline care plan. During an interview on 9/4/24 at 4:22 p.m. the Administrator said Resident #1's care plan that was initiated on 8/27/24 was only for activities and it must have been missed to initiate the rest of the care plan within 48 hours. 2. Record review of the face sheet dated 9/5/24 indicated Resident #2 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including heart failure (a chronic condition in which the heart does not pump blood as well as it should), chronic pain, hypertension (elevated blood pressure), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), need for personal assistance, muscle weakness, and reduced mobility. Record review of the entry MDS dated [DATE] indicated Resident #2 admitted to the facility from a short-term general hospital on 8/266/24. Record review of Resident #1's medical records indicated there was not a baseline care plan. Record review of the comprehensive care plan revised on 9/3/24 indicated Resident #2 focuses were initiated until 9/3/24. Record review of the Baseline Care Plan Acknowledgement dated 8/31/24 indicated Resident #2 had been provided a copy of the baseline care plan. During an interview on 9/4/24 at 1:30 p.m. the ADON said she was the one who reviewed the charge nurse's assessments after a resident was admitted and initiated the care plan. The ADON said she would print the baseline care plan and take it to the resident/resident's family. The ADON said after she printed the baseline care plan and provided it to the resident/resident's family the MDS coordinator was responsible for the comprehensive care plan. The ADON said she did not know how to retrieve the initial care plan she printed off after it was edited by the MDS coordinator. During an interview on 9/4/24 at 4:20 p.m. the ADON said the only care plans the facility had for Resident #1 and Resident #2 were the comprehensive care plans. The ADON said the comprehensive care plans were completed at the facility instead of baseline care plans. The ADON said the care plan initiation date was the date the care plan was completed. During an interview on 9/5/24 at 10:12 a.m. RN A said the DON and ADON had been responsible for completing baseline care plans prior to 9/4/24. RN A said the importance of baseline care plans was to inform staff how to care for a resident and meet their needs. During an interview on 9/5/24 at 12:28 p.m. LVN C said the charge nurse, or any nurse was responsible for the baseline care plan. LVN C said the baseline care plan should be completed on admission however there were times it was carried over to the next shift. LVN C said the importance of the baseline care plan was to let the entire team know the plan of care, how to care for the resident, and be able to recognize progress or decline in a resident. During an interview on 9/5/24 at 12:55 p.m. the DON said the admitting nurse was responsible for completing the baseline care plan. The DON said the baseline care plan should be completed within 48 hours of a resident admitting to the facility. The DON said the nursing administration reviewed new admission to ensure baseline care plans were completed. The DON said the importance of a baseline care plan was so the residents and their families were aware of the goals and treatments the facility had. Record review of the facility's undated Base Line Care Plans policy indicated, Completion and implementation of the baseline care plan within 48 hours of a resident's admission is intended to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events that are most likely to occur right after admission; and to ensure the resident and representative, if applicable, are informed of the initial plan for care and services by receiving a written summary of the baseline care plan. The facility will develop and implement a baseline care plan for each resident that includes the instruction needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan will-Be developed within 48 hours of a resident's admission. Include the minimum healthcare information necessary to care for a resident including, but not limited to-Initial goals based on admission orders; Physician orders; Dietary orders; Therapy services; Social services; and PASARR recommendation, if applicable. The baseline care plan will reflect the resident's stated goals and objectives, and include interventions that address his or her current needs .

Based on observation, interview and record review the facility failed to provide pharmaceutical services, including the accurate acquiring, administering and receipt of all drugs and biologicals, to meet the needs of 1 of 3 (Resident #1) residents reviewed for pharmacy services. The facility failed to ensure Resident #1 was administered her fentanyl (medication used to treat severe pain) transdermal patch (patch that attaches to the skin and contains medication) every 72 hours as ordered. This failure could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications. Findings Include: 1. Record review of the face sheet dated 9/5/24 indicated Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including lung cancer, cancerous neuroendocrine (certain cells that release hormones into the blood in response to stimulation of the nervous system) tumors, alcoholic cirrhosis of the liver (a late stage of alcohol-related liver disease that occurs when the liver is permanently damaged), COPD, and diabetes. Record review of the narcotic count sheet for Resident #1's fentanyl transdermal patches indicated she was administered her fentanyl patch on 8/27/24, 8/29/24, and 8/30/24. Record review of the MAR dated August 2024 indicated Resident #1 had a 25MCG/HR fentanyl patch applied on 8/27/24. The MAR indicate Resident #1 had her fentanyl patch removed and another patch placed on 8/30/24. Record review of the entry MDS dated [DATE] indicated Resident #1 admitted to the facility from home on 8/266/24. Record review of the care plan revised on 8/30/24 indicated Resident #1 had the potential for uncontrolled pain. The care plan indicated Resident #1 was on pain medication with interventions including administer medication as ordered. Record review of the order recap report (report that recaps medications the residents have been ordered and then the order completed or discontinued) dated 9/5/24 indicated Resident #1 had an order for a fentanyl transdermal patch 72 hours 25 MCG/HR (Fentanyl) Apply 1 patch transdermally every 72 hours for pain and remove per schedule starting 8/27/24 and was changed on 9/1/24 to fentanyl transdermal patch 72 hours 25 MCG/HR (Fentanyl) Apply 2 patches transdermally every 72 hours for pain and remove per schedule. During an observation and interview on 9/4/24 at 3:00 p.m. Resident #1 was lethargic and had a difficult time answering the surveyor's questions. Resident #1 said she did not remember her Fentanyl patch ever being changed too early. During an interview on 9/4/24 at 3:24 p.m. MA B said she administered Resident #1's fentanyl patch on 8/29/24 because that was how the MAR read. MA B said she administered Resident #1's fentanyl patch again on 8/30/24 because that was how the MAR read. MA B said she did not compare the MAR to the directions on the controlled drug record because the directions on the controlled drug record were not always correct. MA B said she did not question when the controlled drug record did not match the MAR because she was not a nurse. MA B said she did notice that the order was for 72 hours and it had been less than 72 hours each time she applied Resident #1's fentanyl patch but did not question it because the orders kept changing. During an interview on 9/5/24 at 10:08 a.m. the Hospice Nurse said the family did not want Resident #1 interviewed by anyone including the surveyor due to where she was in her disease process. The Hospice Nurse said Resident #1 being administered a fentanyl patch at 48 hours and then again at 24 hours instead of the ordered 72 hours would not have had any adverse effect on Resident #1 due to her increased pain, anxiety, history of drug abuse, and higher drug tolerance. During an interview on 9/5/24 at 10:12 a.m. RN A said it could be determined whether a medication had been administered or not by referring to the MAR. RN A said if a medication was not documented it was given in the MAR it was not given. RN A said the importance of documenting medication administration in the MAR was to be able to know whether a medication was given and know how to monitor a resident appropriately for adverse reactions. RN A was able to name the 5 rights of medication administration (right person, right time, right medication, right dose, and right route). During an interview on 9/5/24 at 12:28 p.m. LVN C said reviewing the MAR was the way to determine if a medication had been administered or not. LVN C said if a medication was not documented in some way on the MAR, it indicated the medication was not given. LVN C said the importance of ensuring medication administration was documented on the MAR was for staff to be able to know whether a resident received their medication. LVN C was able to name the 5 rights of medication administration. During an interview on 9/5/24 at 12:55 p.m. the DON said he expected staff to ensure they were administering the right medication to the right resident, at the right time. The DON said he expected medication administration to be documented accurately. The DON said to determine whether a medication had been given the MAR could be reviewed. The DON said if medication administration was not documented in the MAR there should be a progress note entered documenting the administration. The DON said he expected nurses and MAs to follow the 5 rights of medication administration. The DON said if an MA noted a discrepancy in the MAR, the times, or on the narcotic count sheet he expected them to go to the charge nurse with this information prior to administering the medication. Record review of the facility's Medication Administration Procedures policy revised on 10/25/17 indicated, All medications are administered by licensed medical and nursing personnel .After the resident ahs been identified, administer the medication and immediately chart doses administered on the medication administration record. it is recommended that the medication be charted immediately after administration, but if the facility permits, the medication may be charted immediately before administration .Defining the schedules for administering medications to: Maximize the effectiveness (optimal therapeutic effect) of the medication; Prevent the potential significant medication interactions such as medication-medication or medication-food interactions; and Honor resident choices and activities, as much as possible, or consistent with the person-centered comprehensive care plan .All current medication and dosage schedules are to be listed on the resident's current medication administration record .

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5 percent. There were 5 errors out of 26 opportunities, resulting in a 19.23 percent medication error rate for 2 of 5 residents reviewed for medication error. (Resident's #72 and #73) The facility did not ensure the following: 1. Resident #72 was given Centrum Silver (Multiple Vitamins-Minerals) as ordered by the physician on 06/18/2024. 2. Resident #72's losartan potassium (blood pressure medication) was not held for a diastolic blood pressure of 63, according to the ordered parameters of hold for diastolic blood pressure less than 90 on 06/18/2024. 3. Resident #73's levetiracetam (anticonvulsant medication) and baclofen (muscle relaxer) were given late on 06/18/2024. 4. Resident #73's nifedipine (blood pressure medication) was not held for a diastolic blood pressure of 84, according to the ordered parameters of hold for diastolic blood pressure less than 90 on 06/18/2024. These failures could place residents at risk for adverse reactions or ineffective dosage related to inaccurate drug administration. The findings included: 1. During an observation on 06/18/2024 beginning at 8:02 AM, MA L obtained Resident #72's blood pressure. The blood pressure was 63 diastolic. MA L prepared Resident #72's medications for administration. MA L placed one tablet from a bottle of multivitamin into the medication cup. MA L placed one tablet from the card losartan potassium .hold for diastolic blood pressure less than 90 into the medication cup. MA L took Resident #72's medication into the room and he took them with a drink of water. Record review of the order summary report, dated 06/18/2024, revealed Resident #72 had the following orders: Centrum Silver Tablet (Multiple Vitamins-Minerals) - Give one tablet by mouth one time a day for vitamin supplement, which started on 03/04/2024. Losartan potassium oral tablet 100 mg - Give one tablet by mouth one time a day related to arrhythmias; Hold for diastolic blood pressure less than 90. Record review of the MAR, dated June 2024, revealed Resident #72 received centrum silver and losartan potassium daily. 2. During an observation on 06/18/2024 beginning at 8:16 AM, MA K obtained Resident #73's blood pressure. The blood pressure was 84 diastolic. MA K prepared Resident #73's medication for administration. MA K placed one tablet from the care of levetiracetam (anticonvulsant medication) into the medication cup. MA K placed one tablet from the card nifedipine .hold for diastolic blood pressure less than 90 into the medication cup. MA K placed one tablet from the card baclofen into the medication cup. MA K took Resident #73's medication into the and she took them with a drink of water. Record review of the order summary report, dated 06/18/2024, revealed Resident #73 had the following orders: Baclofen 10 mg - give one tablet by mouth three times a day for muscle spasms, which started on 01/15/2024. Keppra (levetiracetam) 250 mg - give one tablet by mouth three times a day for seizures, which started on 06/15/2024. Nifedipine 30 mg - give one tablet by mouth one time a day .hold for diastolic blood pressure less than 90, which started on 02/02/2024. Record review of the MAR, dated June 2024, revealed Resident #73 received baclofen, Keppra, and nifedipine daily. The MAR further revealed baclofen and Keppra were scheduled for 7 AM. During an interview on 06/20/2024 beginning at 2:17 PM, MA K stated she had not realized Resident #73's blood pressure medication had a hold parameter for her diastolic blood pressure less than 90. MA K stated those were not the normal parameters and it should have been held for diastolic blood pressure less than 60. MA K stated if she had noticed a medication with a hold parameter outside of the normal, she should have notified the charge nurse so she could have clarified with the doctor. MA K stated Resident #73's Keppra and baclofen were scheduled for 7 AM. MA K stated you had an hour before and an hour after the scheduled time to administer the medication. MA K stated she administered Resident #73's medications late at times depending on what was going on at the facility. MA K stated it was important to ensure medication was given on time to ensure the residents received the effective dosages. MA K stated it was important to ensure medications were held according to the medication parameters to prevent adverse reactions. MA K stated given blood pressure medications outside the parameters could have caused the blood pressure to bottom out. During an interview on 06/20/2024 beginning at 2:21 PM, MA L stated she was unaware Resident #72's blood pressure medication had a hold parameter for his diastolic blood pressure less than 90. MA L stated those were not the normal parameters and it should have been held for a diastolic blood pressure less than 60. MA L stated she should have asked the nurse to clarify the orders with the doctor if the hold parameters were outside of the normal. MA L stated she had not notified the nurse because she was unaware of the parameters. MA L stated the order could have been changed and no one let her know. MA L stated most of the time if a resident has an order for centrum silver, they will administer the house stock or generic unless it was specifically said not to. MA L stated the order should have matched what was given. MA L stated she compared the card or bottle to the MAR during medication administration most of the time. MA L stated she had previous notified a charge nurse that the orders did not match but was unable to specify which charge nurse she had spoken to. MA L stated it was important to ensure medications were given according to the doctor's orders to prevent adverse reactions. MA L stated a blood pressure medication given outside the parameters could have caused Resident #72's blood pressure to drop. During an interview on 06/20/2024 beginning at 5:17 PM, the DON stated normal hold parameters for a diastolic blood pressure were less than 60 not less than 90. The DON stated those parameters for Resident #72 and Resident #73 were likely entered into the system incorrectly. The DON stated the medication aides were familiar with the parameters less than 60 they probably just overlooked it. The DON stated the doctor should have been notified to determine if the bottle of multivitamins could have been substituted with the bottle of Centrum Silver. The DON stated medications could have been given an hour before the scheduled time or an hour after the scheduled time. The DON stated he expected medications to have been given within the required timeframes. The DON stated it was important to administer medications how they were ordered by the physician because it could have affected absorption or the effectiveness of the medications. The DON stated not giving medications as prescribed by the doctor could have caused adverse effects. During an interview on 06/20/2024 beginning at 5:49 PM, the Administrator stated she expected the nursing staff to ensure the policy was followed for medication administration. The Administrator stated nursing management was responsible for monitoring to ensure medications were administered correctly. The Administrator stated it was important to ensure medications were administered per the doctors' orders to help with ailments the residents might have. Record review of the medication administration procedures policy, revised 10/25/2017, revealed .defining the schedules for administering medications to: maximize the effectiveness (optimal therapeutic effect) of the medication, prevent potential significant medication interactions such as medication-medication or medication-food interactions .the 10 rights of medication should always be adhered to: . right medication .right time .right assessment

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Resident #68) reviewed for enhanced barrier precautions, 2 of 2 residents (Resident's #21 and #23) reviewed for respiratory care, 1 of 2 residents (Resident #69) reviewed for wound care, and 1 of 2 residents (Resident #2) reviewed for infection control practices with ADLs . 1. The facility did not ensure LVN F wore enhanced barrier precautions while administering IV medications through Resident #68's PICC line. 2. The facility did not ensure CNA C and CNA D did not contaminate clean linens with soiled linens while providing assistance with ADLs for Resident #2. 3. The facility did not ensure Resident #21, and Resident #23 were tested for the flu or COVID-19 when they developed signs and symptoms. 4. The facility failed to ensure Resident #69 was provided proper wound care. These failures could place residents and staff at risk for cross contamination and the spread of infection. The findings included: 1. Record review of the face sheet, dated 06/19/2024, revealed Resident #68 was a [AGE] year-old male who initially admitted to the facility on [DATE] with diagnosis of pneumonia (lung infection). Record review of the admission MDS assessment, dated 05/30/2024, revealed Resident #68 had clear speech and was understood by others. The MDS revealed Resident #68 was able to understand others. The MDS revealed Resident #68 had a BIMS score of 12, which indicated moderately impaired cognition. The MDS revealed Resident #68 received IV medications while a resident. Record review of the comprehensive care plan, revised 05/30/2024, revealed Resident #68 had IV access and was on enhanced barrier precautions. The interventions included: gloves and gown should be donned if any of the following activities are to occur: linen change, resident hygiene, transfer, dressing, toileting/incontinent care, bed mobility, wound care, enteral feeding care, catheter care, trach care, bathing, or other high-contact activity. During an observation on 06/18/2024 beginning at 1:02 PM, LVN F prepared and administered medication through Resident #68's PICC line. LVN F did not wear a gown while he was performing care with the PICC line. During an attempted interview on 06/20/2024 beginning at 4:06 PM to gather more information LVN F dropped the call and did not return the phone call upon exit of the facility. 2. Record review of the face sheet, dated 06/19/2024, revealed Resident #2 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of cerebrovascular disease (an umbrella term for conditions that impact the blood vessels in your brain), anxiety disorder (group of mental illnesses that cause constant fear and worry),flaccid hemiplegia affecting right dominant side (severe or complete loss of motor function on one side of the body), and obesity (condition characterized by abnormal or excessive fat accumulation). Record review of the quarterly MDS assessment, dated 05/16/2024, revealed Resident #2 had unclear speech and was usually understood by staff. The MDS revealed Resident #2 was usually able to understand others. The MDS revealed Resident #2 had a BIMS score of 14, which indicated no cognitive impairment. The MDS revealed Resident #2 had an impairment of one side to the upper extremities and lower extremities. The MDS revealed Resident #2 was dependent on staff assistance for toilet hygiene and transfers. Record review of the comprehensive care plan, revised on 10/24/2023, revealed Resident #2 had an ADL self-care performance deficit and required staff assistance with transfers and toileting. During an observation on 06/17/2024 beginning at 10:46 AM, CNA C and CNA D provided incontinent care to Resident #2. After incontinent care was finished, CNA C left the soiled linen under Resident #2 and placed the clean mechanical lift pad, clean incontinent brief, and pulled up Resident #2's clean pants. CNA D rolled Resident #2 and finished pulling the clean linen to lay on top of the dirty linen. CNA C and CNA D then attached the Hoyer lift pad to the Hoyer lift and placed Resident #2 in her wheelchair. During an interview on 06/20/2024 beginning at 2:01 PM, CNA C stated she should have made sure the soiled linen was removed before the clean linen was placed on Resident #2. CNA C stated she did not normally place clean linen on top of dirty linen, but she was nervous. CNA C stated it was important to make sure the soiled linen was removed before clean linens were placed to prevent cross contamination and infections. During an interview on 06/20/2024 beginning at 2:41 PM, CNA D stated she should have made sure the soiled linen was removed before placing the clean linens on top during care with Resident #2. CNA D stated clean linen was not supposed to come into contact with soiled linen. CNA D stated it was important to ensure soiled linen was removed before clean linens were placed for infection control. 3. Record review of the face sheet, dated 06/20/2024, revealed Resident #23 was an [AGE] year-old female who initially admitted to the facility on [DATE] with diagnosis of unspecified dementia without behaviors (group of symptoms affecting memory, thinking and social abilities that interferes with daily life) and developed a diagnosis of acute upper respiratory infection on 04/08/2024. The face sheet revealed Resident #23 resided on Hall 5. Record review of the quarterly MDS assessment, dated 03/25/2024, revealed Resident #23 had clear speech and was sometimes understood by others. The MDS revealed Resident #23 was sometimes able to understand others. The MDS revealed Resident #23 had a BIMS score of 13, which indicated no cognitive impairment. The MDS revealed Resident #23 had inattention and disorganized thinking. The MDS revealed Resident #23 had delusions. The MDS revealed Resident #23 had acute respiratory failure with hypoxia and a history of the flu. Record review of the comprehensive care plan, initiated 12/28/2023, revealed Resident #23 declined the flu vaccination. The care plan further revealed Resident #23 had a respiratory infection on 04/06/2024. The care plan further revealed Resident #23 was at risk for signs and symptoms of COVID-19. The interventions included: observe for signs and symptoms of COVID-19, document and promptly report signs or symptoms of: fever, coughing, sneezing, sore throat, respiratory issues. Record review of the order recap report, dated 03/01/2024 to 06/20/2024, revealed Resident #23 had an order which started on 04/06/2024 for azithromycin (antibiotic) and a Medrol dose pack (steroids) for an upper respiratory infection. The order recap further revealed an x-ray was ordered for cough and congestion. Record review of the MAR, dated April 2024, revealed Resident #23 received azithromycin (antibiotic) and Medrol dose pack for an upper respiratory infection. Record review of the progress note, dated 04/06/2024, revealed Rresident #23 was congested and had a cough with yellow sputum. The note further revealed Resident #23 was wheezing, and the doctor ordered medications and a chest x-ray. Record review of the SBAR (assessment used to notify the physician when a resident has a change of condition) assessment, accessed on 06/20/2024, revealed an SBAR assessment had not been completed on 04/06/2024, when Resident #23 developed a cough and congestion. Record review of the Respiratory Screen assessment, accessed on 06/20/2024, revealed a respiratory screen had not been completed on 04/06/2024, when Resident #23 developed a cough and congestion. Record review of the electronic health record, accessed on 06/20/2024, did not indicate any laboratory testing was performed on Resident #23 to include COVID-19 testing or influenza testing. 4. Record review of the face sheet, dated 06/20/2024, revealed Resident #21 was a [AGE] year-old female who admitted to the facility on [DATE] with a diagnosis of pneumonitis due to inhalation of food and vomit (inflammation of lung tissue due to non-infectious causes, which results in cough without mucus or phlegm, shortness of breath and fatigue), fracture of right femur (right hip fracture), and acute postprocedural respiratory failure. The face sheet further revealed Resident #21 resided on Hall 5. Record review of the quarterly MDS assessment, dated 05/21/2024, revealed Resident #21 had clear speech and was understood by others. The MDS revealed Resident #21 was able to understand others. The MDS revealed Resident #21 had a BIMS score of 10, which indicated moderately impaired cognition. The MDS revealed Resident #21 had no behaviors or refusal of care. Record review of the comprehensive care plan, revised 02/23/2024, did not address Resident #21's history of acute upper respiratory infection. Record review of the order recap report dated 04/01/2024 - 06/20/2024, revealed Resident #21 had an order which started on 04/17/2024 for a chest x-ray for cough. The order recap report further revealed an order, which started on 04/18/2024 for azithromycin (antibiotic) and Medrol dose pack (steroids) for an upper respiratory infection. Record review of the MAR, dated April 2024, revealed Resident #21 received azithromycin and Medrol dose pack for an upper respiratory infection. Record review of the progress notes dated 03/20/2024 - 04/20/2024, revealed no entries for 04/17/2024. The progress note dated 04/18/2024, revealed Resident #21's chest x-ray results were negative for pneumonia. The doctor was notified of Resident #21's continued symptoms of productive cough and congestion. The doctor ordered azithromycin and Medrol dose pack. Record review of the SBAR assessment, dated 04/17/2024, revealed Resident #21 had a respiratory change and suspected infection. The SBAR revealed Resident #21 had cold/flu like symptoms which included nasal congestion, dry cough, new or increased cough, and new or increased shortness of breath, which started on 04/16/2024. The SBAR suggested an x-ray and the doctor was notified on 04/17/2024. Record review of the respiratory infection nurses' note, dated 04/18/2024, revealed Resident #21 had nasal congestion and a sore throat. Record review of the respiratory infection nurses' note, dated 04/19/2024, revealed Resident #21 had nasal congestion, fatigue, fever, and cough. Record review of the electronic health record, accessed on 06/20/2024, did not indicate any laboratory testing was completed on Resident #21 to include COVID-19 or influenza testing. During an attempted interview on 06/20/2024 beginning at 4:06 PM to gather more information LVN F dropped the call and did not return the phone call upon exit of the facility. During an attempted interview on 06/20/2024 beginning at 3:14 PM to gather more information LVN M did not answer the telephone or return the call upon exit of the facility. During an interview on 06/20/2024 beginning at 4:21 PM, ADON G stated she believed enhanced barrier precautions were stupid and ridiculous and just another way for the government to earn money. ADON G stated enhanced barrier precautions were required for any residents with an indwelling device. ADON G stated LVN F should have worn enhanced barrier precautions while providing care to Resident #68's PICC line. ADON G stated the nursing staff has had training on enhanced barrier precautions. ADON G stated it was important for staff to ensure they wore enhanced barrier precautions while providing care to not transfer bacteria to the patients. ADON G stated it was important to protect the staff and other residents from the spread of infection. ADON G stated staff should not have placed clean linen on top of soiled linen. ADON G stated she monitored infection control practices during ADL care during checks off or random observations. ADON G stated she had observed staff putting clean linen on top of dirty linens a few times but had not recently. ADON G stated it was important to ensure infection control practices were followed during ADL care so there was no transfer of bacteria from bodily fluids. ADON G stated the signs and symptoms of COVID-19 were similar to other respiratory infections. ADON G stated the signs and symptoms were fever, cough, loss of taste/smell, body pains, and sore throat. ADON G stated if residents had signs or symptoms of COVID-19 or the flu, she would have contacted the doctor to let him decide if testing was required. ADON G stated the facility no longer tested for COVID-19. ADON G stated the facility almost always obtained a chest x-ray. ADON G stated flu testing should have been completed for residents with signs or symptoms of the flu, especially during flu season. ADON G stated Resident #21 and Resident #23 were not tested for COVID-19. ADON G stated Resident #21 might have been tested for the flu but did not believe Resident #23 was tested for the flu . ADON G stated it was the company policy related to the changes with the CDC to no longer automatically jump to COVID-19 testing when symptoms were present. During an interview on 06/20/2024 beginning at 5:15 PM, ADON G stated Resident #21 was not tested for the flu. During an interview on 06/20/2024 beginning at 5:17 PM, the DON stated enhanced barrier precautions should have been used while dealing with a PICC line. The DON stated he expected the nursing staff to utilize the enhanced barrier precautions. The DON stated he was responsible for monitoring to ensure staff were using the enhanced barrier precautions while providing care. The DON stated it was important to use the enhanced barrier precautions for high-risk residents to prevent the spread of multi-drug resistant organisms that could have caused infections. The DON stated he expected nursing staff to ensure infection control practices were followed while providing assistance with ADLs. The DON stated the CNAs, charge nurses, the DON were responsible for monitoring to ensure infection control practices were followed. The DON stated it was important to make sure clean linens were not placed on soiled linen for infection control. The DON stated CDC guidelines were what was followed by the facility for COVID-19 and flu testing. The DON stated the facility did not automatically perform COVID-19 testing when a resident had signs or symptoms. The DON stated an SBAR should have been completed for a change of condition and the doctor should have been notified. The DON stated Resident #21 and Resident #23 were not COVID-19 or flu tested . The DON stated looking back COVID and flu testing should have been performed to ensure respiratory infections did not spread . During an interview on 06/20/2024 beginning at 5:49 PM, the Administrator stated she expected the nursing staff to follow the policy regarding infection control practices. The Administrator stated nursing management and the IDT were responsible for monitoring to ensure infection control policies were followed. The Administrator stated it was important to ensure infection control policies were followed to reduce the spread of infections. 47612 5.Record review of the face sheet, dated 06/18/2024, revealed Resident # 69 was an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of acute cystitis with hematuria (blood cells in the urine, paraplegia, unspecified (paralysis that occurs in the lower half of the body), encephalopathy (damage or disease that affects the brain), pressure ulcer of sacral region, stage 4 ( the blood supply has been so severely cut off that the wound tunnels down through all layers of the skin and exposes bone). Record review of the MDS assessment, dated 05/19/2024, revealed Resident #69 had a BIMS score of 00, which indicated moderately cognitive impairment. The MDS revealed Resident #69 was dependent with two persons assist. The MDS indicated Residents # 69 had a stage 4 pressure ulcer. The MDS indicated Residents # 69 had rejected care. Record review of the comprehensive care plan, revised on 06/4/2024, revealed Resident #69 was at risk for skin breakdown. The interventions revealed Resident #69 frequently refused wound care and the use of a wedge for offloading pressure to promote wound healing. Record review of the order summary, revised on 04/12/2024, revealed Resident #69 special instructions for enhanced barrier precautions, cleanse right Ischium with normal saline, apply calmoseptine to periwound, apply medihoney, apply alginate, cover with dry dressing, start date 05/29/2024. During an interview on 06/18/2024 at 11:58 a.m., Resident #69's family member stated Resident #69 was currently in the hospital with a bone infection in his hip that has no chance of recovery according to the hospital. Resident #69's family member stated the facility staff block his camera in the room when providing care and was unable to see. Resident # 69 family member stated his wound progressively became worse. Resident # 69 family member stated the wound care nurse quit the facility 2 months ago and the facility said the nurses could perform the wound care and she feels they have not been trained properly. Resident #69's family member stated the facilities wound care doctor said he would fire the resident if he went with another provider but ended up firing him anyway. Resident #69's family member stated she had to take him to an outside wound care provider and he was only seen a couple of times before this last time they sent him to ER. Resident #69's family member stated he developed another wound she did not even know about and was not notified of. Resident #69's family member stated she had video of staff members not wearing PPE (personal protective equipment) while providing cares and not following guidelines for performing wound care. During an observation on 06/19/2024 at 9:00 a.m. of date stamped 05/08/2024 at 1:59 p.m., ring video with audio and visual revealed Resident #69 lying left side in bed when ADON G came into view opens gauze package and place gauze into wound with gloved hand and then dressed wound. During an interview on 06/19/2024 at 9:25 a.m., ADON G stated she was the infection preventionist. ADON G stated she had done wound care on Resident #69 several times when he would allow it to be done. ADON G stated Resident #69 would refuse care daily. ADON G stated she would normally wear personal protective equipment when performing wound care and have her supplies on a cleaned bedside table. ADON G stated depending on the wound she would normally use a Q-tip to place the gauze in the wound. ADON G stated she should have been wearing personal protective equipment when performing wound care to prevent infection. During an interview on 06/20/2024 at 3:16 p.m., the DON stated he expected staff to wear personal protective equipment during resident care. The DON stated he does not know why nursing staff was not wearing personal protective equipment during resident care. The DON sated Resident #69 was very difficult and the staff had to perform care quickly when Resident #69 allowed them to. The DON state it was important to wear the personal protective equipment during resident care to prevent infection. The DON stated he would make sure the staff was in serviced on enhanced barrier precautions and the appropriate personal protective equipment to wear during resident care. During an interview on 06/20/2024 at 4:42 p.m., the Administrator stated she expected staff to wear personal protective equipment during resident care The Administrator stated wear personal protective equipment was important for infection control. The Administrator stated the risk to the resident was infection. Record review of the enhanced barrier precautions policy, undated, revealed .enhanced barrier precautions are indicated for residents with any of the following: .wound and/or indwelling medical devices env if the resident is not known to be infected or colonized with a MDRO .indwelling medical device examples include central lines . The policy further indicated gloves and gown should have been worn for device care or use of a central line. Record review of the infection control plan: overview, undated, revealed personnel will handle, store, process and transport linens so as to prevent the spread of infection .the program will: perform surveillance and investigation to prevent, to the extent possible, the onset and the spread of infection . Record review of the procedure for data collection / reporting policy, undated, revealed the facility will use a system of surveillance designed to identify possible communicable disease or infections before they can spread to other persons in the facility .residents who present with signs/symptoms of infection will trigger an infection control entry into the log .the infection preventionist (IP) or designee will may request additional clinical verification of infection as needed for diagnosis by consulting with the attending physician . the IP will have the authority to request additional clinical verification if the patient's condition warrants . Record review of the Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 Pandemic, updated May 8, 2024, revealed anyone with even mild symptoms of COVID-19, regardless of vaccination status, should receive a viral test for SARS-CoV-2 as soon as possible .symptomatic individual identified - residents, regardless of vaccination status, with signs or symptoms must be tested . Record review of the facility's policy titled Infection Control date 5/11/2022, indicated, the facility will establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen. The facility did not ensure: 1. Sanitization buckets were at the appropriate sanitization level on 06/17/2024. 2. DA V failed to wear a hair net while in the kitchen on 06/18/2024. These failures could place residents at risk of cross-contamination and foodborne illness. Findings included: During an observation and interview on 06/17/2024 at 10:10 a.m., the sanitation bucket was located on the bottom of the food preparation and serving area. The bucket was filled approximately 1/3 of the way with a brownish clear liquid and small debris floating on top. The test strip was performed and revealed no sanitizer was in the liquid inside the bucket. [NAME] U stated she had prepared the bucket earlier and the sanitation strip tested at 400. [NAME] U said the purpose of the sanitizer in the sanitation bucket testing at the appropriate level was to prevent the spread of bacteria. During an observation and interview on 06/18/2024 at 11:38 a.m., DA V entered the kitchen without a hair net. DA V stated he had always entered the kitchen without a hairnet to retrieve a hair net from the inside of the kitchen because the hairnets located at the kitchen's entryway did not contain his hair well enough. DA V stated the purpose of the hairnet was to prevent cross contamination and hair in the resident's food. During an interview on 06/20/2024 at 02:15 p.m., Dietary Manager said that she went behind the staff to ensure that the kitchen was being cleaned and everyone was doing the tasks as assigned. The Dietary Manager said she expected the dietary staff to check the sanitation levels in the sanitation buckets appropriately. The Dietary Manager said she expected all dietary staff to wear hair nets at all times. The Dietary Manager stated the purposes of appropriate sanitation levels and wearing hairnets was to prevent cross contamination and provide a sanitary cooking environment. During an interview on 06/20/2024 at 2:24 p.m., Administrator said she expected the Dietary Manager to check behind the staff to ensure that these tasks were completed efficiently. The Administrator said that she expected the kitchen to promote cleanliness and provide a healthy environment for the residents and prevent cross contamination. Record review of the Record review of the Dietary Services policy, last revised on 2012 indicated, .Infection Control: 8. Sanitation of food preparation surfaces A. All kitchenware and food contact surfaces will be cleaned and sanitized after each use. B. Fresh cloths and sanitizer will be used for cleaning all surfaces. Sanitizer will be minimum of 100 ppm chlorine or 25 ppm iodine or 150 - 440 ppm quaternary ammonia - tested using

Based on observation, interview and record review, the facility failed to ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs for 3 of 37 residents (Resident #54, # 41 and #76) reviewed for food form in that: 1.The facility did not ensure Resident #54 had diet orders or received meals that addressed her potential for malnutition. 2. The facility did not ensure Resident #41 was given double protein portion as ordered by the physician. 3. The facility did not ensure Resident #76 chicken parmesan was chopped as ordered by the physician. This failure could place residents at risk of not receiving food to meet their needs. Findings Included: 1.Record review of the face sheet, dated 06/20/2024, revealed Resident # 54 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of major depressive disorder (a persistently low or depressed mood), hypothyroidism ( a common condition where the thyroid does not create or release enough thyroid hormone into your bloodstream), anxiety disorder ( a condition in which a person has excessive worry and feelings of fear, dread and uneasiness. Record review of the order summary report, dated 06/11/2024, revealed Resident #54 orders does not address her diet. Record review of the MDS assessment, dated 06/05/2024, revealed Resident #54 made herself understood and understood others. The assessment indicated Resident #54 BIMS score was 15, which indicated her cognition was intact. The assessment indicated Resident #54 had no behaviors or refusal of care. The assessment indicated Resident #54 did have a weight loss of 5%. The assessment did not address Resident #54's diet. Record review of the comprehensive care plan, revised on 06/13/2024, indicated Resident #54 had a potential for malnutrition. The interventions included: monitor resident's weight, offer diet as ordered by the physician and update food preferences as needed. During an observation on 06/17/2024 at 12:38 p.m., Resident #54 received a single serving of the entree which was pot roast. During an interview and observation on 06/17/2024 at 12:40 p.m., ADON O was asked by the surveyor if Resident #54 entree was considered a large portion. ADON stated, she was not sure she would have to check with the cook. During an interview on 06/20/2024 at 1:06 p.m., [NAME] P stated he did not work on 06/17/2024. [NAME] P stated Resident #54 should have gotten one-and a half piece of meat. [NAME] P stated it was the cook, Dietary Manager, and nursing staff responsibility to make sure the trays were correct before serving residents. [NAME] P stated this failure could potentially put residents at risk for weight loss. During an interview on 06/20/2024 at 1:26 p.m., the Dietary Manager stated she expected physician orders to be followed. The Dietary Manager stated Resident #54 should have received one and a half pieces of meat for a large portion of protein. The Dietary Manager stated if Resident #54 does not receive the correct portion it could put her at risk for weight loss. The Dietary Manager stated she would monitor as the staff fixed the residents plates. During an interview on 06/20/2024 at 3:16 p.m., the DON stated nurses were responsible for checking food trays prior to giving them out to residents. The DON stated it was important for Resident #54 to receive the ordered portion. The DON stated Resident #54 was on supplements for weight loss due to her disease process. The DON stated the risk to the resident was decrease in protein and weight loss. During an interview on 06/20/2024 at 4:42 p.m., the Administrator stated she expected dietary staff to follow the physician orders. the Administrator stated she expected the food trays to be checked and residents to receive the correct diet. The Administrator stated it was important for residents to receive the correct diet order because it contribute to their overall care and health. The Administrator stated the dietary and nursing were responsible for monitoring and overseeing. 2. Record review of the face sheet, dated 06/19/2024, indicated Resident #41 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included unspecified fracture of lower end of right femur. Record review of the order summary report, dated 06/19/2024, indicated Resident #41 had an order, which started on 03/16/2024, for regular diet regular texture, regular consistency, double protein portions at every meal. Record review of the admission MDS assessment, dated 03/22/2024, indicated Resident #41 made herself understood and understood others. The assessment indicated Resident #41 BIMS score was 13, which indicated her cognition was intact. The assessment indicated Resident #41 had no behaviors or refusal of care. The assessment indicated Resident #41 did not have weight loss of 5%. The assessment did not address Resident #41's diet. Record review of the comprehensive care plan, revised on 05/28/2024, indicated Resident #41 had a potential for malnutrition. The interventions included: monitor resident's weight, offer diet as ordered by the physician and update food preferences as needed. During an observation on 06/17/2024 at 12:38 p.m., Resident #41 received a single serving of the entree which was pot roast. During an interview and observation on 06/17/2024 at 12:39 p.m., ADON O was asked by the surveyor if Resident #41 entree was considered double. ADON stated, no and took the tray back to the kitchen to request for another serving of protein. 3. Record review of the face sheet, dated 06/19/2024, indicated Resident #76 was a [AGE] year-old female originally admitted to the facility on [DATE] with diagnoses which included malignant neoplasm (cancerous tumor) of unspecified part of unspecified bronchus (extension of the trachea). Record review of the order summary report, dated 06/19/2024, indicated Resident #76 had an order, which started on 02/26/2024, for regular diet regular texture, regular consistency, chopped meat. Record review of the admission MDS assessment, dated 02/08/2024, indicated Resident #76 made herself understood and understood others. The assessment indicated Resident #76 BIMS score was 15, which indicated her cognition was intact. The assessment indicated Resident #76 had no behaviors or refusal of care. The assessment indicated Resident #76 did not have weight loss of 5%. The assessment did not address Resident #76's diet. Record review of the comprehensive care plan, revised on 02/19/2024, indicated Resident #76 had a potential for malnutrition. The interventions included: monitor resident's weight, offer diet as ordered by the physician and update food preferences as needed. During an observation on 06/17/2024 at 12:35 p.m., Resident #76 received small, cubed pieces of chicken parmesan. During an interview and observation on 06/17/2024 at 12:36 p.m., ADON O was asked by the surveyor if Resident #76 entree was considered chopped. ADON stated, no, it's cubed and took the tray back to the kitchen to request for meat to be chopped. During an interview on 06/20/2024 at 1:06 p.m., [NAME] P stated he did not work on 06/17/2024 but the chicken should have been served chopped instead of cubed. [NAME] P stated when a meat was chopped it should be between cubed and mechanical. [NAME] P stated a knife was used to chop up the meat. [NAME] P stated Resident #41 should have gotten double serving instead of single. [NAME] P stated it was the cook, Dietary Manager and nursing staff responsibility to make sure the trays were correct. [NAME] P stated ultimately the nursing department were responsible for ensuring the trays were correct before serving a resident. [NAME] P stated this failure could potentially put residents at risk for choking and weight loss. During an interview on 06/20/2024 at 1:26 p.m., the Dietary Manager stated the cook should have chopped the meat with a knife prior to handing the tray to the nursing staff. The Dietary Manager stated Resident #41 should have gotten double portions. The Dietary Manager stated she expected physician orders to be followed. The Dietary Manager stated the cook, herself and the nursing department were responsible for checking the trays prior to serving the residents. The Dietary Manager stated usually when the cook started to fix the residents plate, she was there to monitor and oversee. The Dietary Manager stated every now and then she would catch a tray incorrect and have the staff to redo the tray. The Dietary Manager stated staff were verbally in-serviced immediately. The Dietary Manager stated this failure could put residents at risk for choking and weight loss. During an interview on 06/20/2024 at 3:11 p.m., the DON stated nurses were responsible for checking food trays prior to giving them out to residents. The DON stated #76 patty should have been cut up in smaller pieces. The DON stated it was chopped but not finely. The DON stated Resident #41 should have gotten double protein serving. The DON stated when he checked the trays on 06/17/2024 he thought they were correct. The DON stated, I can't catch everything. The DON stated this failure could put residents at risk for difficulty chewing/swallowing, decrease in protein and weight loss. During an interview on 06/19/2024 at 3:44 p.m., the Administrator stated she expected the food trays to be checked and residents to receive the correct diet. The Administrator stated it was important for residents to receive the correct diet order because it contribute to their overall care and health. The Administrator stated the dietary and nursing were responsible for monitoring and overseeing. Record review of the facility's undated policy titled Resident Menus indicated, we will strive to assure the resident's nutritional needs are provided based on the RDA. The standard menu will ensure nutritional adequacy of all diets, offer a variety of food in adequate amounts at each meal, and standardize food production . 5. The Dietary Service Manager and cooks are trained and responsible for the preparation and service of therapeutic diets as prescribed . Record review of the facility's undated policy titled Physician's Orders indicated . to monitor and ensure the accuracy and completeness of the medication orders, treatment orders, and ADL order for each resident . Record review of the facility's undated policy titled Diet Order/Diet Manual did not address chopped or double portions diet. 43047

Based on observation, interview, and record review the facility failed to ensure that residents were free of significant medication errors for 2 of 5 residents reviewed for medication administration. (Resident's #72 and #73) 1. Resident #72's losartan potassium (blood pressure medication) was not held for a diastolic blood pressure of 63, according to the ordered parameters of hold for diastolic blood pressure less than 90 on 06/18/2024. 2. Resident #73's levetiracetam (anticonvulsant medication) was given late on 06/18/2024. 3. Resident #73's nifedipine (blood pressure medication) was not held for a diastolic blood pressure of 84, according to the ordered parameters of hold for diastolic blood pressure less than 90 on 06/18/2024. These failures could place the resident at risk of medical complications and not receiving the therapeutic effects of their medications. The findings included: 1. During an observation on 06/18/2024 beginning at 8:02 AM, MA L obtained Resident #72's blood pressure. The blood pressure was 63 diastolic. MA L prepared Resident #72's medications for administration. MA L placed one tablet from the card losartan potassium .hold for diastolic blood pressure less than 90 into the medication cup. MA L took Resident #72's medication into the room and he took them with a drink of water. Record review of the order summary report, dated 06/18/2024, revealed Resident #72 had an order for Losartan potassium oral tablet 100 mg - Give one tablet by mouth one time a day related to arrhythmias; Hold for diastolic blood pressure less than 90. Record review of the MAR, dated June 2024, revealed Resident #72 received losartan potassium daily. 2. During an observation on 06/18/2024 beginning at 8:16 AM, MA K obtained Resident #73's blood pressure. The blood pressure was 84 diastolic. MA K prepared Resident #73's medication for administration. MA K placed one tablet from the care of levetiracetam (anticonvulsant medication) into the medication cup. MA K placed one tablet from the card nifedipine .hold for diastolic blood pressure less than 90 into the medication cup. MA K took Resident #73's medication into the and she took them with a drink of water. Record review of the order summary report, dated 06/18/2024, revealed Resident #73 had the following orders: Keppra (levetiracetam) 250 mg - give one tablet by mouth three times a day for seizures, which started on 06/15/2024. Nifedipine 30 mg - give one tablet by mouth one time a day .hold for diastolic blood pressure less than 90, which started on 02/02/2024. Record review of the MAR, dated June 2024, revealed Resident #73 received Keppra and nifedipine daily. The MAR further revealed the Keppra was scheduled for 7 AM. During an interview on 06/20/2024 beginning at 2:17 PM, MA K stated she had not realized Resident #73's blood pressure medication had a hold parameter for her diastolic blood pressure less than 90. MA K stated those were not the normal parameters and it should have been held for diastolic blood pressure less than 60. MA K stated if she had noticed a medication with a hold parameter outside of the normal, she should have notified the charge nurse so she could have clarified with the doctor. MA K stated Resident #73's Keppra was scheduled for 7 AM. MA K stated you had an hour before and an hour after the scheduled time to administer the medication. MA K stated she administered Resident #73's medications late at times depending on what was going on at the facility. MA K stated it was important to ensure medication was given on time to ensure the residents received the effective dosages. MA K stated it was important to ensure medications were held according to the medication parameters to prevent adverse reactions. MA K stated given blood pressure medications outside the parameters could have caused the blood pressure to bottom out. During an interview on 06/20/2024 beginning at 2:21 PM, MA L stated she was unaware Resident #72's blood pressure medication had a hold parameter for his diastolic blood pressure less than 90. MA L stated those were not the normal parameters and it should have been held for a diastolic blood pressure less than 60. MA L stated she should have asked the nurse to clarify the orders with the doctor if the hold parameters were outside of the normal. MA L stated she had not notified the nurse because she was unaware of the parameters. MA L stated the order could have been changed and no one let her know. MA L stated she compared the card or bottle to the MAR during medication administration most of the time. MA L stated it was important to ensure medications were given according to the doctor's orders to prevent adverse reactions. MA L stated a blood pressure medication given outside the parameters could have caused Resident #72's blood pressure to drop. During an interview on 06/20/2024 beginning at 5:17 PM, the DON stated normal hold parameters for a diastolic blood pressure were less than 60 not less than 90. The DON stated those parameters for Resident #72 and Resident #73 were likely entered into the system incorrectly. The DON stated the medication aids were familiar with the parameters less than 60 they probably just overlooked it. The DON stated medications could have been given an hour before the scheduled time or an hour after the scheduled time. The DON stated he expected medications to have been given within the required timeframes. The DON stated it was important to administer medications how they were ordered by the physician because it could have affected absorption or the effectiveness of the medications. The DON stated not giving medications as prescribed by the doctor could have caused adverse effects. During an interview on 06/20/2024 beginning at 5:49 PM, the Administrator stated she expected the nursing staff to ensure the policy was followed for medication administration. The Administrator stated nursing management was responsible for monitoring to ensure medications were administered correctly. The Administrator stated it was important to ensure medications were administered per the doctors' orders to help with ailments the residents might have. Record review of the medication administration procedures policy, revised 10/25/2017, revealed .defining the schedules for administering medications to: maximize the effectiveness (optimal therapeutic effect) of the medication, prevent potential significant medication interactions such as medication-medication or medication-food interactions .the 10 rights of medication should always be adhered to: .right time .right assessment .

Based on observations, interviews, and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 1 of 24 residents (Resident #50) reviewed for resident rights. The facility did not ensure CNA S treated residents with dignity and respect when feeding two residents at the same time during the lunch meal. This failure could place residents at an increased risk of embarrassment, isolation, and diminished quality of life. The findings included: Record review of the face sheet, dated 06/18/2024, revealed Resident # 50 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of Alzheimer's disease (disease that destroys memory and other important mental functions), spinal stenosis, lumbar region without neurogenic claudication (compression of the spinal nerves in the lumbar (lower) spine), dysphagia (swallow difficulties). Record review of the MDS assessment, dated 04/25/2024, revealed Resident #50 had a BIMS score of 00, which indicated severe cognitive impairment. The MDS did not address eating assistance. Record review of the comprehensive care plan, revised on 05/14/2024, revealed Resident #50 interventions required one person assist with eating. During an observation on 06/20/2024 at 12:30 p.m. CNA S was observed feeding Resident # 50 and another resident at the same time. During an interview on 06/20/2024 at 1: 10 p.m. Resident # 50's family member stated the staff always feeds another resident while feeding Resident #50. Resident # 50 family member state they feel Resident # 50 was rushed to eat because the facility does not have enough staff to feed the residents that need assistance. During an interview on 06/20/2024 at 1:45 p.m., CNA S stated she feeds to residents at the same time when they do not have enough staff. CNA S stated she tried to give each resident the attention they need. CNA S stated it was important to give the resident the time and attention they deserve while eating. CNA S stated the risk to the resident was they may not get enough food or feel bad about themselves. During an interview on 06/20/2024 at 3:16 p.m., the DON stated the CNAs feed two residents at a time for staff utilization. The DON stated the alternative was the residents who need assistance would have to wait longer for their meal. The DON state it was important to feed the residents before the food gets cold. During an interview on 06/20/2024 at 4:42 p.m., the Administrator stated it could be common for the CNAs to feed two residents at the same time. The Administrator stated the alternative would be the family could hire someone to assist with feeding. The Administrator stated this could negatively affect Resident #50 by making her not want to eat in the dining room. Record review of the facility's policy titled Resident Rights indicated The facility must treat each resident with respect and dignity and care for each resident in a manner and in a environment that promotes maintenance and enhancement of his or her quality of life .

Based on observation, interview, and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 24 residents (Resident #2) reviewed for reasonable accommodation of needs. The facility did not ensure Resident #2's call light was answered timely and within reach when leaving her room on 06/17/2024. This failure could place residents at risk for unmet needs and decreased quality of life. The findings included: Record review of the face sheet, dated 06/19/2024, revealed Resident #2 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of cerebrovascular disease (an umbrella term for conditions that impact the blood vessels in your brain), anxiety disorder (group of mental illnesses that cause constant fear and worry),flaccid hemiplegia affecting right dominant side (severe or complete loss of motor function on one side of the body), and obesity (condition characterized by abnormal or excessive fat accumulation). Record review of the quarterly MDS assessment, dated 05/16/2024, revealed Resident #2 had unclear speech and was usually understood by staff. The MDS revealed Resident #2 was usually able to understand others. The MDS revealed Resident #2 had a BIMS score of 14, which indicated no cognitive impairment. The MDS revealed Resident #2 had an impairment of one side to the upper extremities and lower extremities. The MDS revealed Resident #2 was dependent on staff assistance for toilet hygiene and transfers. Record review of the comprehensive care plan, revised on 10/24/2023, revealed Resident #2 had an ADL self-care performance deficit. The interventions included: Encourage resident to use bell to call for assistance. During an observation and interview on 06/17/2024 beginning at 3:24 PM, Resident #2 was sitting up in her wheelchair in her room beside her bed. Resident #2 had the call light on, but the call light was laying in the floor beside her chair. Resident #2 stated she wanted to lay down and needed to be changed. Resident #2 said when she pressed the call light it had fallen on the ground, and she was unable to reach over her wheelchair to get it. Resident #2 stated she was waiting for a staff member to answer her call light. During an observation on 06/17/2024 at 3:30 PM, CNA E went into Resident #2's room and turned out the call light. CNA E then walked out of Resident #2's room. During an observation on 06/17/2024 at 3:35 PM, Resident #2's call light remained on the ground beside her wheelchair. During an observation and interview on 06/17/2024 beginning at 3:38 PM, Resident #2 wheeled herself outside her room into the hallway. Resident #2 said she was unable to get her call light off the ground. Resident #2 stated a staff member had come into her room and turned the call light off and had not returned yet. Resident #2 said staff members turned her call light off all the time and did not come back. Resident #2 stated she was tired of it. CNA E walked by Resident #2 sitting in the hallway and did not explain why she had not returned to her room. During an observation on 06/17/2024 at 3:43 PM, The DOR was walking by Resident #2 in the hallway. The DOR asked Resident #2 if she needed anything and Resident #2 stated she needed to be put down to bed and changed. Resident #2 explained she had already told a staff member what she needed, and that staff member had turned out her call light, walked out of her room, and had not returned. The DOR stated she would finish what she was doing and then return to help her. CNA E was standing at the nurses' station visible from 400 Hall. During an observation on 06/17/2024 beginning at 3:48 PM, The DOR walked into Resident #2's room with her supplies. She was followed by CNA E. During an interview on 06/20/2024 beginning at 3:07 PM, CNA E stated she had worked at the facility for approximately 6 months. CNA E said she normally worked Hall 4. CNA E stated she answered Resident #2's call light on 06/17/2024 and she had requested to have been changed and laid down. CNA E stated she had told another CNA who was assigned to Resident #2, but she told her Resident #2 was going to have to hang on as she was working her way down the hallway. CNA E stated she told the charge nurse but did not notify or explain the situation to Resident #2. CNA E said she did not realize Resident #2's call light was on the ground when she entered her room to answer the call light. CNA E stated she should have made sure the call light was in reach before she left the room. CNA E stated it was important to ensure the call light was left in reach so the residents could have used it. During an interview on 06/20/2024 beginning at 5:17 PM, the DON stated he expected facility staff to ensure a resident's call light was left within reach. The DON said all staff were responsible for ensuring call lights were left in reach. The DON said it was important to ensure call lights were left in reach so the residents could have called for help and assistance. During an interview on 06/20/2024 beginning at 5:49 PM, the Administrator stated she expected staff to ensure call lights were left within reach and answered timely. The Administrator stated all staff were responsible for ensuring call lights were left within reach. The Administrator stated it was important to ensure call lights were left within reach so the residents could have used them. The policy for call lights was requested but not provided upon exit of the facility.

Based on interview and record review, the facility failed to ensure each resident was informed before, or at the time of admission, and periodically during the residents stay, of services available in the facility and of changes for those services, which included changes for services not covered under Medicare/Medicaid or by the facility's per diem rate for 1 of 3 residents (Resident #183) reviewed for Medicare/Medicaid coverage. The facility failed to ensure Resident #183 was given a SNF ABN when discharged from skilled services at the facility prior to covered days being exhausted. This failure could place residents at risk for not being aware of changes to provided services. Findings included: Record review of Resident #183's face sheet, dated 06/19/2024, indicated Resident #183 was a [AGE] year-old male, originally admitted to the facility on [DATE] with diagnoses which included hypokalemia (low potassium). Record review of admission MDS assessment, dated 04/25/2024, indicated Resident #183 sometimes made himself understood and sometimes understood others. The assessment indicated Resident #183's BIMS score was 3, which indicated his cognition was severely impaired. The assessment indicated Resident #183 was receiving speech, occupational and physical therapy. Record review of the SNF Beneficiary Protection Notification Review indicated Resident #183 was receiving Medicare Part A services starting on 04/19/2024 and the last covered day of Part A services was 05/09/2024, However, a SNF ABN was not completed which would have informed Resident #183 of the option to continue services at the risk of out of pocket. During an interview on 06/20/2024 at 9:00 a.m., MDS Coordinator A stated she was responsible for ensuring Resident #183 was issued a SNF ABN. MDS Coordinator A stated Resident #183 had 60 days remaining. MDS Coordinator A stated the form should have been issued if the resident had skilled benefit days remaining and was being discharged from Part A services and continued living in the facility. When asked why the form was not given, MDS Coordinator A stated, It got missed. MDS Coordinator A stated it was important to ensure residents received the form because it notified the family and resident that there was a possibility that they could be responsible for extra charges that the insurance would not cover. MDS Coordinator A stated there was a not a risk because his needs were met. During an interview on 06/20/2024 at 3:44 p.m., the Administrator stated the MDS Coordinators were responsible for ensuring the SNF ABN was completed. The Administrator stated the regional coordinator was responsible for monitoring and overseeing. The Administrator stated it was important for residents to receive the SNF ABN so they are aware of how many days they have left that the insurance will pay. Record review of the facility's' policy effective 04/30/2018, titled Creative Solution in Healthcare Policy and Procedure SNF ABN, indicated, a SNF ABN must be given to the beneficiary in order to transfer financial liability for the item or service to the beneficiary . Record review of CMS guidelines Beneficiary Notice Guidelines, approved by CMS-10124-DENC December 31, 2011, indicated Scenario Part A stay will end because: SNF (Skilled Nursing Facility) determines the beneficiary no longer requires daily skilled services. Resident has days remaining in the benefit period. Resident will remain in the facility (custodial care) Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) CMS-10055 (2018) and Notice of Medicare Non-Coverage (NOMNC) CMS-10123 (12/31/11)) to be completed .

Based on observation, interview, and record review, the facility failed to ensure adequate supervision and assistance devices to prevent accidents for 1 of 7 (Resident #1) residents reviewed for accidents. The facility failed to ensure CNA A and CNA B transferred Resident #1 with a mechanical lift resulting in Resident #1 losing his balance during the transfer and being lowered to the floor. An x-ray indicated Resident #1 had left trimalleolar fracture (a fracture of the lower leg sections that form the ankle joint and help move the foot and ankle). These failures could place residents at risk for injuries due to inadequate supervision. Findings include: 1. Record review of the consolidated Physician Orders dated 4/28/23 indicated Resident #1 was a [AGE] year-old male, admitted the to the facility on [DATE] with diagnoses including cerebral palsy (a congenital disorder of movement, muscle tone, or posture), chronic pain, osteoarthritis of bilateral knees (a type of arthritis that occurs when flexible tissue at the ends of bones wears down), and trochanteric bursitis of the right hip (common type of chronic hip pain. Record review of the admission MDS dated [DATE] indicated Resident #1 admitted from an acute hospital on 2/15/23. Record review of the care plan last revised 3/03/23 indicated Resident #1 was at risk for falls related to a history of falls with current fall with major injury. The care plan indicated interventions included use of mechanical lift with 2-person staff assist for transfer starting on 2/22/23. Record review of the Admission Nurse Note dated 2/15/23 indicated Resident #1 required a mechanical lift for transfers. Record review of the Fall-Risk assessment dated [DATE] indicated Resident #1 was unable to stand. Record review of the Visual/Bedside Kardex Report dated 2/22/233 indicated Resident #1 required use of mechanical lift with 2-person staff assist for all transfers. Record review of the nursing progress note dated 2/22/23 indicated, Resident #1 requested to get up and out of bed for noon meal, while CNAs assisting the resident with transfer lost strength and was assisted to the floor. Resident #1 stated his left ankle hurt and felt like it had popped . Record review of the Event Nurses-Note 12hr Fall dated 2/22/23 indicated Resident #1 had a witnessed assisted fall. The Event Nurses-Note 12hr Fall indicated Resident #1 complained of sharp pain 8 out of 10 on the pain scale to his left ankle. Record review of the orthopedic physician's note dated 2/2823 indicated Resident #1 had visited the physician for a one-week follow-up related to left ankle fracture. The orthopedic physician's note indicated imaging was performed on Resident #1's left ankle with results of left trimalleolar fracture with left ankle stable positioning alignment. During an interview on 4/27/23 at 10:24 a.m. Resident #1 said everything was going great at the facility. Resident #1 said when he stood up and put weight on his legs they gave out. Resident #1 said the CNAs lowered him to the floor and one of his legs was bent under him. Resident #1 said he heard a pop and knew he had broken something. Resident #1 said the transportation aide had relayed to the staff he required a mechanical lift for transfers. He said the CNAs did not bring a mechanical lift to his room to transfer him. During an interview on 4/27/23 at 10:55 a.m. CNA B said she remembered the incident involving Resident #1 on 2/22/23. CNA B said he was a new admission and she and another CNA went in to transfer him to his wheelchair upon his request. CNA B said Resident #1 told them he could transfer with 2-person assist. CNA B said she did not look in the kiosk/Kardex to see how Resident #1 was supposed to be transferred. CNA B said she did not know how to work the kiosk/Kardex at that time. CNA B said she just went by what the resident told her. CNA B said she did not think to ask the nurse or anyone about Resident #1's transfer status but should have. CNA B said Resident #1 legs gave out during the transfer and he was lowered to the floor. During an interview on 4/27/23 at 12:56 p.m. the Transportation Aide said she had transported Resident #1 to the facility when he admitted . The Transportation Aide said she had told a facility clinical staff member that Resident #1 required a mechanical lift for transfers. The Transportation Aide said she did not remember which staff member she had told this information to. The Transportation Aide said the facility she had picked Resident #1 up from had relayed this information to her prior to him discharging to the facility. During an interview on 4/28/23 CNA C said if a resident was newly admitted CNAs should check the care plan and ask the nurse what the resident's transfer status was. CNA C said staff should not take a resident's word for what their transfer status was because the resident could be confused or not aware of their transfer status and could get hurt during transfer if transferred inappropriately. During an interview on 4/28/23 at 10:14 a.m. CNA E if a resident was newly admitted CNAs should check the Kiosk, ask the nurse, or consult with therapy regarding the residents transfer status. CNA E said staff should not take the residents word for what their transfer status was because the resident may not remember they cannot walk, may have forgotten the had a broken hip, or may be confused. CNA E said it was important to know the appropriate transfer status of a resident to prevent injury to the resident or staff by inappropriate transfer. During an interview on 4/28/23 at 10:29 a.m. LVN D said the transfer status of a newly admitted resident was relayed in report from the discharging facility, found in the discharge paperwork, or relayed by the physician. LVN D said the transfer status of a resident should be entered into the plan of care which populates into the kiosk for the CNAs to access. LVN D said the CNAs were able to look in the kiosk, ask the nurse, or should have been given report by the nurse to know what a newly admitted resident's transfer status was. LVN D said CNAs should not take resident's word for what their transfer status was because they were unaware of the newly admitted residents' mental status and ability to relay accurate information. LVN D said the importance of appropriate transfers was to ensure resident did not sustain further injury or a new injury. During an interview on 4/28/23 at 11:42 a.m. the DON said when the nurse completed the new admission assessment on a resident there was an area regarding mobility and transfer status of a resident. The DON said the new admission assessment then opened the baseline care plan for the nurse to go in and complete. The DON said once the baseline care plan was completed the information should merge into the Kardex/kiosk system for the CNAs to access. The DON said the Kardex/kiosk system gave the CNAs information regarding a resident's level of care including their transfer status. The DON said baseline care plans should be completed on admission to communicate what level of care a resident need. The DON said if the baseline care plan was not completed and the transfer status information was not in the Kardex/kiosk system then the CNAs should ask the charge nurse prior to transferring a resident. The DON said staff should not take the resident's word for how they are supposed to be transferred. The DON said the importance of ensuring residents were transferred appropriately was to avoid injury to the resident or staff. Record review of the facility's Preventive Strategies to Reduce Fall Risk revised 10/05/16 indicated, The goal of fall prevention strategies is to design interventions that minimize fall risk by elimination or managing contributing factors while maintaining or improving the resident's mobility. After risk is assessed, individualized nursing care plans will be implemented to prevent falls .

Based on observation, interview, and record review, the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range by failing to provide nutritional and hydration care and services to Resident, consistent with the resident's comprehensive assessment for 1 of 15 Residents (Resident #108) reviewed for weight loss. The facility did not follow dietary recommendations or implement physicians' orders to prevent Resident #108 from having significant weight loss. Resident #108 had a 6.77% (10.4 pounds) significant weight loss from 12/10/2021 to 1/10/2022 and a 9.15% (13.1 pounds) severe weight loss from 1/10/2022 to 2/10/2022 These failures could place residents at risk for decreased nutritional status, decline in health, serious illness or hospitalization . Findings included: Record review of consolidated physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the most recent comprehensive MDS dated [DATE] indicated Resident #108 usually made self-understood and usually understands others. The assessment indicated a BIMS score of 6 indicating severe cognitive impairment. The assessment indicated Resident #108 did not reject care necessary to achieve the resident's goals for health or well-being. The assessment indicated Resident #108 did not have physical or verbal behavior symptoms directed toward others. The MDS indicated Resident #108 required extensive assistance with bed mobility, activity did not occur for transfers, limited assistance toilet use, supervision with personal hygiene, total dependence with bathing and walking did not occur. The MDS indicated Resident #108 was 66 inches tall and weighed 150 pounds. Record review of a quarterly MDS dated [DATE] indicated Resident #108 weighed 130 pounds, had a weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months and was not on a physician prescribed weight-loss regimen. Record review of the care plan dated 3/22/2022 with a date initiated of 11/22/2021 and a revision date of 12/15/2021 indicated Resident #108 had a diet order other than regular and was at risk for unplanned weight loss or gain, the interventions included; determine food preferences and provide dietary limitations, encourage meal completion and document amount consumed, monitor weight per facility protocol, offer sub, if resident eats less than 50%, praise the resident for eating well, dietician assessment per facility protocol, serve diet and snacks as ordered, the resident had a mechanically altered diet. Record review of a weight log indicated Resident #108 weighed: *151.2 pounds 11/24/2021 *150 pounds 11/26/2021 *152.7 pounds 12/1/2021 *153.6 pounds 12/10/2021 *143.2 pounds 1/10/2022 *130.1 pounds 2/10/2022 *131.6 pounds 3/14/2022 Further review of a weight log indicated Resident #108 had a 6.77% significant weight loss from 12/10/2021 to 1/10/2022 and a 9.15% severe weight loss from 1/10/2022 to 2/10/2022. Record review of dietary recommendations dated January 25th-26th 2022 for Resident #108 indicated the dietician recommended fortified cereal at breakfast. Multivitamin with minerals daily, vitamin C daily, Zinc daily, Med Pass 90ml three times daily. Liquid protein 30ml twice daily, [MEDICATION(S)] or Juven 1 packet twice a day and encourage hydration with physician signature date of agreement on 1/28/2022. Record review of dietary recommendations dated February 24th-25th 2022 for Resident #108 indicated the dietician recommended. Multivitamin with minerals daily, Med Pass 120ml three times daily. Liquid protein 30ml twice daily. Fortified cereal at breakfast and house shake with lunch and dinner meals. Encourage hydration and snacks between meals with physician signature date of agreement on 3/2/2022. Record review of January's 2022 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of February's 2022 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of March 2022 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Liquid Protein two times a day for weight loss give 30mls can mix in 4oz beverage for taste ordered 3/2/2022. Med Pass three times a day for Weight loss Give 120mls ordered 3/2/2022. Multivitamin-Minerals Tablet (Multiple Vitamins-Minerals) Give 1 tablet by mouth one time a day for weight loss, pressure injuries, ordered 3/2/2022. During an observation on 3/22/2022 at 1:19 p.m., Resident #108 had eaten 100% of ground chicken fried steak, 50% of peas, 50% of ready shake strawberry, 0% of potatoes 0% of cornbread, 0% honey bun, 100% of Tea. During an interview on 3/22/2022 at 2:47 p.m., LVN G said weights were done once a month and CNAs or restorative were responsible for obtaining weights. She said weights should pop up on the MAR and the nurses pass it on to the aides. She said resident's health could decline with weight loss and orders not being implemented. During an interview on 3/22/2022 at 2:48 p.m., CNA F said she had previously been responsible for getting resident's weights, but the task was just reassigned to all of the CNAs. She said nurses would notify the CNAs if a resident needed to be weighed. She said the ADON gives them a list at the beginning of the month for monthly weights, and everyone in the building is weighed on the 1st of every month. CNA F said staff had 5 days to get everyone weighed. She said if they had a new admit, they were weighed weekly for the first 4 weeks. During an interview on 3/22/2022 at 3:05 p.m., LVN E said if she noticed weight loss she would check a residents weight. She said daily weights would show up on nurses orders and they would pass it on the CNA to obtain. LVN E said monthly weights were done by shower aides and she does not know where the weight list comes from. She said they have a program called weight watchers for residents with weight loss. LVN E said a resident's health could decline if weights were not monitored and orders were not implemented. During an observation on 3/22/2022 at 3:26 p.m., Resident #108 refused to be weighed. During an interview on 3/23/2022 at 11:09 a.m., the Corporate Compliance Nurse she said she did not find any evidence that dietary recommendations for January 2022 or February2022 were initiated by staff after the physician agreed to start them for Resident #108. She said the orders for January and February were not implemented. During an interview on 3/23/2022 at 1:08 p.m., the Corporate Compliance Nurse said the DON/ADON should follow up to see if the physician signs dietary recommendations. She said the DON keeps the dietary recommendation book and the recommendations should be placed in the physician's book to be signed when he visits weekly. The Corporate Compliance Nurse said the facility has not had a DON since the first week of January 2022. She said it was the ADON's responsibility to follow up to ensure the dietician recommendations were being signed since they did not have a DON. During an interview on 3/23/2022 at 1:23 p.m., CNA F said Resident #108 was normally weighed in a wheelchair when she was taken for her shower. She said the scale was in the shower room. CNA F said if there was a difference in weight since the last weight, they will also use the hoyer lift to weigh residents to make sure the scale was not off. During an interview on 3/23/2022 at 1:27 p.m., The Physician said if he had seen Resident #108's dietary recommendations, they would have a signature on them. He said he was in the facility every Friday afternoon to sign things. He said weight loss was a common problem for nursing home residents and he could not recall which residents had weight loss and which ones did not. He said he expected staff to follow written orders. During an interview on 3/23/2022 at 1:50 p.m., LVN E said she did not know how weight loss was monitored. She said the ADON/DON had a weight loss book. During an interview on 3/23/2022 at 2:21 p.m., the RD (Registered Dietician) said she sends dietary recommendations through a group e-mail to the DON, ADON, Administrator and Dietary monthly. She said she attached a letter to the physician on the e-mail for his signature of approval or disapproval. The RD said she does not follow up on every resident in the building monthly and said it depended on who she was following up on that day. She said she would expect the physician to sign yes or no on the recommendations and the nursing staff to enter the order if the physician agreed. The RD said she relied on staff to get the physician the dietary recommendations. She said she has no way of knowing if the physician sees her recommendations. The RD said she does not check to see if the orders have been initiated or implemented. She said a resident's health could decline if weights were not monitored and orders were not implemented. During an interview on 3/23/2022 at 2:38 p.m., the ADON said she was responsible for making sure the dietary recommendations get in the physician's book to be signed. She said the RD makes her recommendations and she places them in the physician's book to be signed. She said they were usually signed within 5 days or when the physician came into the facility to see residents and view his book. She said she only checks to see if they were signed when she has time and thinks about it. The ADON said she did not have a system for checking to see if dietary recommendations were signed or put in the computer as an order. She said the physician was in the building Friday, Saturday, and Sunday this week and did not sign pharmacy recommendations. The ADON said she was only one person and could only do so many things and was not a miracle worker. She said she felt responsible for the dietary recommendations not being implemented. The ADON said a resident could decline over a period of 5 days if an order was not implemented. During an interview on 3/23/2022 at 2:40 p.m., The RD said she does not write orders. During an interview on 3/23/2022 at 2:48 p.m., the Corporate Compliance Nurse said the physician did sign some of the dietary recommendations, but the staff did not enter the orders for January 2022 or February 2022 into the EMR. She said she does not know how it was missed. The Corporate Compliance Nurse said she did not know there was an issue with the physician signing recommendations and the staff should have told her so she could intervene. During an interview on 3/23/2022 at 4:41 p.m., the Administrator said she expected orders to be implemented when a physician approves dietary recommendations. She said residents could decline, have skin breakdown, or further weight loss if orders were not followed through. She said desired weight loss should be care planned. Record review of a facility policy titled Resident Weight with a revision date of 2/13/2007 indicated all resident will be weighed by the 10th of the month and their weights documented correctly .the appropriate actions regarding significant changes will be carried out .weights shall be obtained and documented at admission, readmission, and monthly unless ordered otherwise by the physician, or unless dictated more frequently by the resident 's condition .factors indicating the need for more frequent weights include significant weight loss, drastic decrease in food consumption . Whenever possible, all weights are to be completed by the same employee who has been trained in the weighing process. Scales should be balanced prior to use. Scales should be calibrated periodically for accuracy. It is best to keep the scales in a permanent location, as moving it frequently affects accuracy. Residents are to be weighed on the same scale each month . Monthly weights will be obtained prior to the 10th of the month. The DON or designee will review all weights to determine the need for any re-weighs. Re-weighs will be completed within 24 hours of the first weight . Significant Weight Loss: The facility review resident weights after monthly weights are obtained, to determine residents with significant weight changes. A significant weight change will be defined as 5% or greater in one month, 7.5% or greater in three months, or 10% or greater in six months. The weight change will be recorded on the appropriate weight watcher's form along with interventions, and follow-up will also be recorded in the designated location. The physician and family will be notified. In addition, an acute care plan for weight loss will be initiated and the clinical record reviewed for possible need of a significant change of condition MDS assessment . All significant weight changes will be referred to the Regional Dietitian on the next visit. The Regional Dietitian will generate a copy of the facility weight report and can review the weight watchers' forms in PCC. The Regional Dietitian will complete an assessment on all significant weight losses. The Regional Dietitian will review all facility interventions, and will make appropriate recommendations, which will be approved by the physician, if necessary .

Based on interview and record review, the facility failed to consult with the physician regarding a change in condition for 1 of 5 residents reviewed for change of condition. (Resident #2) The facility failed to notify the physician, of Resident #2's multiple blood sugar readings of less than 70 mg/dl. An Immediate Jeopardy (IJ) was identified at 9:00 a.m. on 4/16/21. While the IJ was removed on 4/16/21, the facility remained out of compliance a severity level of actual harm that is not Immediate Jeopardy and a scope of isolated due to the facility's ongoing evaluation of the effectiveness of the corrective systems. These failures resulted in an identification of an Immediate Jeopardy (IJ) at 9:00 a.m. on 4/16/21. While the IJ was removed on 4/16/21, the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems This failure could place residents as at risk of seizures, diabetic coma, or death. Findings included: The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The order stated to notify the physician for a blood sugar reading less than 70 The admission MDS dated [DATE] indicated Resident #2 was admitted to the facility on [DATE] from an acute care hospital. The MDS indicated Resident #2 understood others with clear comprehension and made himself understood. The MDS indicated Resident #2 had moderate cognitive impairment and had no behavior of rejecting care. The MDS indicated Resident #2 had an active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS indicated Resident #2 had no changes in his insulin orders during the 7 day look back period. The care plan initiated on 2/11/21 indicated Resident #2 had diabetes mellitus. The care plan interventions included administer diabetes medication as ordered by the doctor and monitor/document for side effects and effectiveness. The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The summary report indicated Resident #2 was discharged from the facility on 3/30/21. The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This order was in effect until 4/1/21. The vitals summary for February and March 2021 indicated Resident #2 had a blood sugar of less than 70 mg/dl (Milligrams per deciliter ) following dates and times; *2/25/21 at 7:13 a.m., FSBS (finger stick blood sugar) reading of 67; the blood sugar was not rechecked until 11:45 a.m.; *3/4/21 at 6:40 a.m., FSBS reading of 55; the blood sugar was not rechecked until 11:57 a.m.; *3/4/21 at 5:05 p.m., FSBS reading of 67; *3/5/21 at 7:02 a.m., FSBS reading of 56; the blood sugar was not rechecked until 11:46 a.m.; *3/6/21 at 11:52 a.m., FSBS reading of 60; the blood sugar was not rechecked until 6:06 p.m.; *3/10/21 at 5:40 a.m., FSBS reading of 69; the blood sugar was not rechecked on this day; *3/11/21 at 6:57 a.m., FSBS reading of 49; the blood sugar was not rechecked 11:20 a.m.; *3/12/21 at 7:16 a.m., FSBS reading of 46; the blood sugar was not rechecked until 11:16 a.m.; *3/14/21 at 8:16 a.m., FSBS reading of 67; the blood sugar was not rechecked until 1:44 p.m.; *3/22/21 at 7:09 a.m., FSBS reading of 49; the blood sugar was not rechecked until 11:31 a.m.; *3/23/21 at 12:29 a.m., FSBS reading of 56; the blood sugar was not rechecked until 10:44 a.m.; *3/23/21 at 10:44 a.m., FSBS reading of 39; *3/29/21 at 1:18 a.m., FSBS reading of 50; the blood sugar was not re-checked until 7:15 a.m.; and *3/29/21 at 7:15 a.m., FSBS reading of 42; the blood sugar was not rechecked until 11:30 a.m. The nursing notes for February 2021 -March 2021 did not indicate the physician had been notified regarding the blood sugar readings less than 70 mg/dl on the following dates and times; *2/25/21 at 7:13 a.m., FSBS reading of 67; *3/4/21 at 6:40 a.m., FSBS reading of 55; *3/4/21 at 5:05 p.m., FSBS reading of 67; *3/5/21 at 7:02 a.m., FSBS reading of 56; *3/6/21 at 11:52 a.m., FSBS reading of 60; *3/10/21 at 5:40 a.m., FSBS reading of 69; *3/11/21 at 6:57 a.m., FSBS reading of 49; *3/12/21 at 7:16 a.m., FSBS reading of 46; *3/14/21 at 8:16 a.m., FSBS reading of 67; *3/23/21 at 12:29 a.m., FSBS reading of 56; *3/23/21 at 10:44 a.m., FSBS reading of 39; *3/29/21 at 1:18 a.m., FSBS reading of 50; and *3/29/21 at 7:15 a.m., FSBS reading of 42. The nursing note dated 3/23/21 at 12:56 a.m., indicated Resident #2's blood sugar was 56 and a snack was given. The next nursing note dated 3/23/21 at 11:29 a.m., indicated Resident #2's blood sugar was 39 at 7:30 and he was unresponsive. The note indicated an emergency [MEDICATION(S)] injection and glucagel was administered and the blood sugar was 40 at 7:45 after the administration. The note indicated Emergency services were called and IV glucose was administered. The note indicated Resident #2's blood sugar 246 at 8:43 a.m. and he was provided a meal. The note did not indicate that the physician had been notified. The nursing note dated 3/23/21 at 9:20 pm indicated Resident #2 had vomited. The note did not indicate his blood sugar was checked. During an interview on 4/14/21 at 7:00 p.m. the former DON said she was sure the nurses had notified the medical director regarding his hypoglycemic episodes because she thought the medical director had decreased his insulin. During an interview on 4/15/21 at 2:00 pm, LVN E said she took care of Resident #2 often while he was at the facility. LVN E said she was sure she had notified Resident #2's physician regarding his many hypoglycemic incidents. LVN E said she was sure he told her to give Resident #2 something to eat. During an interview on 4/15/21 at 3:00 p.m., LVN M said she did not notify the physician during the hypoglycemic event that occurred on her shift because of how late it was. LVN M said she was sure she reported the event to the on-coming shift. LVN M said she thought she rechecked Resident #2's blood sugar later but could not say for sure. During an interview on 4/15/21 at 3:35 p.m., the DON said nurses should notify the physician if a FSBS is below the ordered parameters. The DON said nurses should recheck a FSBS after an intervention was provided for a low blood sugar. During an interview on 4/16/21 at 9:20 a.m., the medical director said he had been notified of one hypoglycemic event on 3/22/21. He said LVN E notified him Resident #2 FSBS was 49 but had improved after a snack. He said LVN E said the resident was not eating well. The medical director said he ordered a medication to stimulate Resident #2's appetite. The medical director said he was not notified of any additional hypoglycemic episodes. The medical director said if he would have been notified of repeated episodes he would have made changes to Resident #2's antidiabetic medication and insulin. The American Diabetes Association website accessed on 4/22/21 at https://www.diabetes.org/healthy-living/medication-treatments/blood-glucose-testing-and-control/[CONDITION(S)], stated Low blood sugar is when your blood sugar levels have fallen low enough that you need to [MEDICATION(S)] to bring them back to your target range. This is usually when your blood sugar is less than 70 mg/dL . The only sure way to know whether you are experiencing low blood sugar is to check your blood sugar, if possible. If you are experiencing symptoms and you are unable to check your blood sugar for any reason, treat the [CONDITION(S)] . Signs and symptoms of low blood sugar happen quickly. From milder, more common indicators to most severe, signs and symptoms of low blood sugar include: Feeling shaky; Being nervous or anxious; Sweating, chills and clamminess; Irritability or impatience; Confusion; Fast heartbeat; Feeling lightheaded or dizzy; Hunger; Nausea; Color draining from the skin (pallor); Feeling sleepy; Feeling weak or having no energy; Blurred/impaired vision; Tingling or numbness in the lips, tongue or cheeks; Headaches; Coordination problems, clumsiness; Nightmares or crying out during sleep; and Seizures. A low blood sugar level triggers the release of [MEDICATION(S)] (adrenaline), the fight-or-flight hormone. [MEDICATION(S)] is what can cause the symptoms of [CONDITION(S)] such as thumping heart, sweating, tingling and anxiety. If the blood sugar level continues to drop, the brain does not get enough glucose and stops functioning as it should. This can lead to blurred vision, difficulty concentrating, confused thinking, slurred speech, numbness, and drowsiness. If blood sugar stays low for too long, starving the brain of glucose, it may lead to seizures, coma and .death . The 15-15 rule-have 15 grams of carbohydrate to raise your blood sugar and check it after 15 minutes. If it's still below 70 mg/dL, have another serving. Repeat these steps until your blood sugar is at least 70 mg/dL. Once your blood sugar is back to normal, eat a meal or snack to make sure it doesn't lower again . The Mayo Clinic website accessed on 4/22/21 at https://www.mayoclinic.org/diseases-conditions/[CONDITION(S)]/symptoms-causes/syc- 685, stated .[CONDITION(S)] needs immediate treatment when blood sugar levels are low. For many people, a fasting blood sugar of 70 milligrams per deciliter (mg/dL), or 3.9 millimoles per liter (mmol/L) .Untreated [CONDITION(S)] can lead to; seizure; loss of consciousness; death .Over time, repeated episodes of [CONDITION(S)] can lead to [CONDITION(S)] unawareness. The body and brain no longer produce signs and symptoms that warn of a low blood sugar, such as shakiness or irregular heartbeats. When this happens, the risk of severe, life-threatening [CONDITION(S)] increases . The facility policy titled Glucometer, revised on 2/13/2007 stated, .Abnormal Results (1) Notify the physician if the blood glucose is outside of any physician specific parameters and implement any new orders prescribed . The administrator was notified on 4/16/21 at 10:03 a.m. that an Immediate Jeopardy situation was identified due to the above failures. The administrator was provided the Immediate Jeopardy template on 4/16/21 at 10:05 a.m. The facility's Plan of Removal was accepted on 4/16/21 at 6:15 p.m. and included: Interventions: 100% blood sugar audit by 5pm today by Administrative nurses and Corporate Compliance Nurse Physician will be notified of all blood sugars outside the parameters of scale by 5pm today. The following in-services were initiated 4/16/21 by Regional Compliance Nurse: Any nurse not present or in-serviced on 4/16/21 will not be allowed to assume their duties until in-serviced: Following facility policy for [CONDITION(S)] located in the Glucometer policy: Abnormal Results 1. Notify the physician if the blood glucose is outside of any physician specific parameters and implement any new orders as prescribed 2. If the resident has an order for [MEDICAL RECORD OR PHYSICIAN ORDER] 3. If no order for [MEDICATION(S)]: a. If the resident is responsive and can swallow, administer orange juice with sugar added or glucose gel b. If the resident is unresponsive notify emergency medical services. Notified Medical Director of IJ situation on 4/16/21 at 10:56am. Monitoring: DON/Designee will review 5-8 residents slide scale results for proper notification to MD if outside parameters weekly x 4 weeks. DON/Designee will monitor all blood sugars outside parameters of slide scale for notification to MD weekly x 4 weeks. Regional Compliance Nurse will DON/Designee for monitoring compliance weekly x 4 weeks. The QA Committee will review findings and Physician Notification Policy and will make changes as needed monthly. One 4/16/21 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Seven LVNs (on all shifts - 6 a.m. to 2 p.m.; 2 p.m. to 10 p.m.; and 10 p.m. to 6 a.m.); four nurses on the weekend shifts (6 a.m. to 10 p.m. on Saturdays and Sundays); one MDS Nurse; and the ADON said they were in-serviced on facility policy for [CONDITION(S)], established parameters for M.D. notification and prompt notification related to FSBS. Verification of 100% blood sugar audit by the administrative nurses and corporate compliance Nurse was completed. Residents with ordered parameters in place had the physician notified of blood sugars outside of ordered parameters. All diabetic residents had ordered parameters in place. On 4/16/21 at 7:20 p.m., the administrator was informed the IJ was removed; however, the facility remained out of compliance at actual harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to ensure the resident had the right to be free from abuse for 2 of 7 (Residents #1 and #6) residents reviewed for abuse. The facility failed to protect Resident #1 and Resident #6 from being threatened and verbally abused by LVN H, a night shift staff. Resident #1 reported multiple times to the Social Worker and Administrator that LVN H was threatening and verbally abuse, but the facility failed to take any actions to protect the resident. Resident #1 became fearful, lost sleep, and was sleeping with a cane for protection. An Immediate Jeopardy (IJ) situation was identified on 4/16/21. While the IJ was removed on 4/16/21, the facility remained out of compliance at a severity level of actual harm that is not Immediate Jeopardy and a scope of isolated due to the facility's ongoing evaluation of the effectiveness of the corrective systems. This failure could place residents at risk for serious physical or psychological harm or injury. Findings included: 1. Record review of Resident #1's consolidated physician orders, dated 4/12/21, revealed Resident #1 was [AGE] years old and admitted on [DATE] with [DIAGNOSES REDACTED]. The orders indicated Resident #1 discharged from the facility on 4/12/21 to another skilled nursing facility. Record review of Resident #1's MDS, dated [DATE], revealed Resident #1 was usually understood, sometimes understood others, and was cognitively intact. The MDS indicated Resident #1 required supervision with bed mobility, transferring, dressing, eating, toileting, personal hygiene, and bathing. The MDS indicated Resident #1 had no hallucinations, delusions, or behavioral symptoms during the look back period. Record review of Resident #1's care plan, initiated on 11/2/20 and updated/closed on 4/13/21, revealed Resident #1 had behavioral problems related to mental health, could be manipulative, dishonest, and cried excessively. The care plan indicated Resident #1 was approached and spoken to in a calm manner, attention diverted and removed from the situation. The care plan indicated Resident #1 had a communication problem related to anxiety and would misinterpret conversations. The care plan indicated Resident #1 had a history of [REDACTED]. The care plan indicated Resident #1 was allowed to verbalize her feelings and was allowed time to calm down. The care plan indicated Resident #1's behaviors was analyzed for key times, places, circumstances, triggers and what would de-escalate the behavior. The care plan indicated Resident #1 had a mood problem related to past trauma and mental health. The care plan indicated Resident #1 would be happier, calmer, and have no signs and symptoms of depression, anxiety, or sadness. The care plan indicated Resident #1 would be assisted to identify her strengths and positive coping skills, and these would be reinforced. Review of Resident #1's social service notes, completed by the SW, revealed the following entries: 1/5/21 at 11:08 a.m.- Resident #1 disclosed depression and paranoia. The note indicated Resident #1 reported having difficulty being alone and reported she did not feel safe. The note indicated Resident #1 reported since she had her leg amputated, she did not feel she could react quickly if something were to happen. 1/5/21 at 1:34 p.m.-- Resident #1 had experienced restless sleep the last couple nights and paranoia. 1/14/21 at 11:40 a.m.-Resident #1 voiced concerns regarding staff members. The noted indicated Resident #1 disclosed some paranoia and requested a roommate. The note indicated Resident #1 had a history of [REDACTED]. Record review of the facility investigation report dated 4/6/21 did not indicate the investigation included interviews with staff related to LVN H's behavior towards the residents. The investigation indicated the following actions were taken after the investigation was completed: * the SW completed satisfaction surveys with residents and would complete 5 to 8 residents surveys every week for four weeks; *the staff were in-serviced on abuse and neglect, grievances, and resident rights; and *LVN H was re-instated with education on abuse and neglect, resident rights, and grievances. Record review of a face sheet dated 4/7/21 indicated Resident #1's room number was 614. Record review of staff daily sign in sheets indicated Halls 500-700 were at Nurses' station 2. The sign in sheets indicated LVN H worked as the night shift nurse at Station 2 (Halls 500-700) 17 times during February 2021, 14 times during March 2021, and once during April 2021. The sign in sheets indicated LVN H worked as the night shift nurse at Station 2 (Halls 500-700) on the following dates: 2/3/21, 2/4/21, 2/5/21, 2/6/21, 2/9/21, 2/11/21, 2/12/21, 2/15/21, 2/16/21, 2/17/21, 2/18/21, 2/21/21, 2/22/21, 2/23/21, 2/24/21, 2/27/21, 2/28/21, 3/1/21, 3/2/21, 3/5/21, 3/6/21, 3/7/21, 3/11/21, 3/12/21, 3/13/21, 3/14/21, 3/18/21, 3/19/21, 3/20/21, 3/25/21, 3/26/21, and 4/5/21. During an interview on 4/16/21 at 9:55 a.m., the SW said Resident #1 reported LVN H yelling and being threatening to her and the previous administrator on multiple occasions. The SW did not know when the yelling or threatening behaviors occurred, and she did not make any notes of the reports by Resident #1. The SW said she thought the previous DON knew about Resident #1's complaints. The SW said Resident #1 became fixated on things and on everything, and she exaggerated. The SW said she did not make notes or document Resident #1's complaints specifically because she was told the previous administrator was handling the complaints. The SW said she did not recall what Resident #1's complaints about LVN H were, but she remembered Resident #1 did not like LVN H and thought LVN H did not like her also. The SW said she completed satisfaction rounds with other residents and no other residents complained about LVN H. Record review of Resident #1's nurse's note dated from 12/1/20 to 4/12/21 indicated she reported difficulty sleeping on 12/19/20, 12/21/20, 1/5/21, 1/29/21, 2/8/21, 2/10/21, 3/3/21, 3/4/21, 3/8/21, 3/9/21, and 3/15/21. Record review of Resident #1's nurse's note written by the current DON dated 4/6/21 at 3:30 p.m. indicated Resident #1 was upset about a staff member. The note indicated Resident #1 was asked if she had any injuries or had been hurt and Resident #1 denied having any injuries or being hurt. During an interview on 4/15/21 at 3:15 p.m., MA C said Resident #1 reported she was afraid of LVN H. MA C said Resident #1 reported she did not feel safe to sleep at night and did not sleep. MA C said Resident #1 slept with a cane for protection from LVN H. MA C said she reported Resident #1's complaints to the charge nurses, the previous DON, and the social worker. MA C said LVN H continued to work with Resident #1 and there were no interventions placed to protect Resident #1. During an interview on 4/15/21 at 5:32 p.m., the current DON said Resident #1 reported allegations of threatening behaviors against LVN H on 4/6/21 and LVN H was suspended immediately for half a day. The DON said the SW completed satisfaction rounds with other residents and found no concerns with LVN H The DON said she did not interview staff or obtain written statements about how LVN H treated residents. The DON said the current administrator might have interviewed staff. During an interview on 4/15/21 at 6:09 p.m., the current administrator said during mid-March 2021 he came to the facility during the night shift and observed LVN H. The administrator said he did not observe any concerns regarding the care LVN H provided. The administrator said during his investigation of the reports of verbal threats by Resident #1 staff were not interviewed regarding LVN H. The administrator said the SW completed satisfaction rounds with the residents and no other resident reported complaints about LVN H. The administrator said he encouraged staff to be open with their communication and no staff had called him to report concerns regarding LVN H. During a telephone interview on 4/16/21 at 9:21 a.m., Resident #1 was interviewed regarding her allegations against LVN H. During the interview Resident #1 was very emotional, her voice was shaky, and she continued to express fear of Resident #1. Resident #1 said LVN H would stand at the foot of her bed some nights and yell at her for using her call light more than one time. Resident #1 said LVN H told her to only use her call light one time during the night. Resident #1 said LVN H yelled at her and made her cry. Resident #1 said she reported LVN H's behavior to the SW and the previous administrator. Resident #1 said that she did not feel safe at night and began sleeping with a wooden cane in her bed for protection. Resident #1 said she slept with a cane in her bed from approximately November 2020 to March 2021. Resident #1 said she could not sleep at night due to being so fearful. Resident #1 said she would not sleep on the nights LVN H worked due to fear. Resident #1 said an agency nurse, name unknown, witnessed LVN H yelling at her one night. Resident #1 said one night, date unknown, she had not received her pain medication and was afraid to ask. She said she finally built up enough courage to go ask LVN H for the medication. Resident #1 said LVN H yelled at her and told her to go to her room and she would not give Resident #1 her pain medication until she went to her room. Resident #1 said she called the previous administrator and reported LVN H and requested a CNA to be present when LVN H came into her room. Resident #1 was tearful and said she was really afraid of LVN H. Resident #1 said LVN H would make the CNA stand in the hallway outside of her room and made Resident #1 believe there was not a CNA present. Resident #1 said she reported multiple instances of LVN H's yelling and threatening behavior to the previous DON and previous administrator and LVN H continued to work with Resident #1. Resident #1 said she started to feel hopeless because when she told the previous DON and previous administrator nothing was done to protect her. Resident #1 said her family wanted to call the corporate staff, but she was afraid since nothing had been done to stop LVN H's behaviors. Resident #1 said when the new administrator came to the facility on an unknown date, she did not have the courage to tell him because of how her previous complaints had been blown off by the previous DON and previous administrator. Resident #1 said in April 2021 she finally had enough courage to tell the current DON her concerns about LVN H. Resident #1 said the administrator was notified and the police were called. Resident #1 said the next day after she reported LVN H to the current administrative staff, she felt like other staff (laundry and housekeeping) were treating her different. Resident #1 said that was one of the reasons she decided to move to another skilled nursing facility. Resident #1 said she felt relieved to be in a facility she did not have to worry about LVN H yelling at her and being threatening. 2. Record review of Resident #6's consolidated physician orders [REDACTED].#6 was [AGE] years old and admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #6's most recent MDS revealed Resident #6 sometimes understood others, sometimes made himself understood, and had moderate cognitive impairment. The MDS indicated Resident #6 required supervision with bed mobility, transferring, and eating; limited assistance with dressing and personal hygiene; and extensive assistance with toileting and bathing. Review of Resident #6's care plan updated on 4/14/21 indicated Resident #6 had a communication problem related to cognitive impairment. The care plan indicated Resident #6 had difficulty expressing his wants and would become frustrated at times. Observation on 4/15/21 at 1:05 p.m., revealed Resident #6 was ambulating in the hallway and was not interviewable. During an interview on 4/15/21 at 3:29 p.m., RN A said LVN H was verbally threatening to residents especially Resident #6. RN A said she reported LVN H's behaviors to the previous DON. RN A said the previous DON blew off the allegations. RN A said she had reported LVN H's concerning behaviors to the previous DON and previous administrator and they both blew off the allegations. During an interview on 4/15/21 at 6:09 p.m., the current administrator said he was not aware of any reports from staff that LVN H had yelled at Resident #6. The administrator said he would immediately start an investigation and LVN H would be suspended pending the results of his investigation. During an interview on 4/16/21 at 11:06 a.m., the previous DON said during a care plan meeting, date unknown, Resident #1 had mentioned concerns about LVN H but did not report her yelling, threatening her, or that she was afraid of LVN H. The previous DON said Resident #1 did not like her and she could not remember if any staff had reported concerns regarding LVN H. Record review of an Abuse/Neglect policy updated on 11/7/16 indicated, .The resident has the right to be free from abuse .Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff .The facility will provide and ensure the promotion and protections of Resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse .mistreatment of [REDACTED].Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse .and mental abuse including abuse facilitated or enabled through the use of technology. Willful .means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm .verbal abuse .saying things to frighten a resident .The facility will determine the direction of the investigation based on a thorough examination of events .any person having reasonable cause to believe an elderly or incapacitated adult is suffering from abuse .must report this to the DON, administrator .employee will make an immediate verbal report to the Abuse Preventionist or designee .The facility will take necessary measures to protect residents and employees from harm .following an abuse .all allegations will be investigated regardless of identification of caller .Each resident has the right to be free from all types of abuse, including mental abuse .This facility establishes an environment that is as homelike as possible and includes a culture and environment that treats each Resident with respect and dignity. Treating a nursing home Resident in any manner that does not uphold a resident's sense of self-worth and individuality dehumanizes the resident and creates an environment that perpetuates a disrespectful and/or potentially abusive attitude towards the resident(s) . The administrator was notified on 4/16/21 at 10:03 a.m. that an Immediate Jeopardy situation was identified. The administrator was provided the Immediate Jeopardy template on 4/16/21 at 10:05 a.m. The facility's Plan of Removal was accepted on 4/16/21 at 6:15 p.m. and included: Interventions: One on One in-service on Abuse Investigation with the Administrator/DON; Staff working with Alleged perpetrator have been interviewed; Alleged perpetrator has been terminated; Resident safe surveys have been completed; The following in-services were initiated by the ADO and regional nurse on 4/16/21: Any staff member not present or in-serviced on 4/16/21, will not be allowed to assume their duties until in-serviced: All Staff Abuse/Neglect; Abuse/Neglect Reporting; and Who to Report Abuse/Neglect to The medical director was notified of the immediate jeopardy situation on 4/16/21 at 10:56 a.m. Monitoring Administrator to Investigate and submit findings to ADO and Risk Management for review Administrator will submit documentation of investigation with Resident and Staff interviews, as well as weekly follow up interviews with staff and residents x 4 weeks to ensure resident safety/satisfaction with outcome of investigation ADO will monitor weekly x 4 weeks documentation The QA committee will review findings monthly and makes changes as needed. Confirmation of the facility's implementation of their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) included: Interviews with seven LVNs, eleven CNAs (from all three shifts), one MA (on the 6 a.m. to 2 p.m. shift),four nurses on the weekend shifts (6 a.m. to 10 p.m. on Saturdays and Sundays); one housekeeper, three dietary staff, one MDS Nurse, the maintenance director, the ADON, the DON and the administrator said they were in-serviced on abuse/neglect, reporting abuse/neglect, and who to report abuse/neglect to. They all said they would report all allegations of abuse/neglect to the DON and administrator. All staff interviewed said all allegations of abuse would be reported and would be taken seriously. Review of the alleged perpetrator's personnel file confirmed she was terminated. On 4/16/21 at 7:20 p.m., the administrator was informed the IJ was removed; however, the facility remained out of compliance at a severity level of actual harm that is not Immediate Jeopardy with a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview and record review, the facility failed to ensure all alleged violations involving abuse were thoroughly investigated and failed to prevent further potential abuse for 1 of 7 residents reviewed for abuse and neglect. (Resident #1) The facility failed to thoroughly investigate allegations of abuse made by Resident #1 against LVN H and keep Resident #1 safe from further abuse. Resident #1 reported multiple times to the Social Worker and Administrator that LVN H was threatening and verbally abuse, but the facility failed to take any actions to protect the resident. Resident #1 became fearful, lost sleep, and was sleeping with a cane for protection. An Immediate Jeopardy (IJ) situation was identified on 4/16/21. While the IJ was removed on 4/16/21, the facility remained out of compliance at a severity level of actual harm that is not Immediate Jeopardy and a scope of isolated due to the facility's ongoing evaluation of the effectiveness of the corrective systems. This failure could place residents at risk for abuse, neglect, and a decreased quality of life. Findings included: 1. Record review of Resident #1's consolidated physician orders, dated 4/12/21, revealed Resident #1 was [AGE] years old and admitted on [DATE] with [DIAGNOSES REDACTED]. The orders indicated Resident #1 discharged from the facility on 4/12/21 to another skilled nursing facility. Record review of Resident #1's MDS, dated [DATE], revealed Resident #1 was usually understood, sometimes understood others, and was cognitively intact. The MDS indicated Resident #1 required supervision with bed mobility, transferring, dressing, eating, toileting, personal hygiene, and bathing. The MDS indicated Resident #1 had no hallucinations, delusions, or behavioral symptoms during the look back period. Record review of Resident #1's care plan, initiated on 11/2/20 and updated/closed on 4/13/21, revealed Resident #1 had behavioral problems related to mental health, could be manipulative, dishonest, and cried excessively. The care plan indicated Resident #1 was approached and spoken to in a calm manner, attention diverted and removed from the situation. The care plan indicated Resident #1 had a communication problem related to anxiety and would misinterpret conversations. The care plan indicated Resident #1 had a history of [REDACTED]. The care plan indicated Resident #1 was allowed to verbalize her feelings and was allowed time to calm down. The care plan indicated Resident #1's behaviors was analyzed for key times, places, circumstances, triggers and what would de-escalate the behavior. The care plan indicated Resident #1 had a mood problem related to past trauma and mental health. The care plan indicated Resident #1 would be happier, calmer, and have no signs and symptoms of depression, anxiety, or sadness. The care plan indicated Resident #1 would be assisted to identify her strengths and positive coping skills, and these would be reinforced. Review of Resident #1's social service notes, completed by the SW, did not indicate any reports of abuse or concerns regarding staff made to the SW by Resident #1 were investigated by the administrator or the abuse coordinator. The notes revealed the following entries: 1/5/21 at 11:08 a.m.- Resident #1 disclosed depression and paranoia. The note indicated Resident #1 reported having difficulty being alone and reported she did not feel safe. The note indicated Resident #1 reported since she had her leg amputated, she did not feel she could react quickly if something were to happen. 1/5/21 at 1:34 p.m.-- Resident #1 had experienced restless sleep the last couple nights and paranoia. 1/14/21 at 11:40 a.m.-Resident #1 voiced concerns regarding staff members. The noted indicated Resident #1 disclosed some paranoia and requested a roommate. The note indicated Resident #1 had a history of [REDACTED]. Record review of a face sheet dated 4/7/21 indicated Resident #1's room number was 614. Record review of staff daily sign in sheets indicated Halls 500-700 were at Nurses' station 2. The sign in sheets indicated LVN H worked as the night shift nurse at Station 2 (Halls 500-700) 17 times during February 2021, 14 times during March 2021, and once during April 2021. The sign in sheets indicated LVN H worked as the night shift nurse at Station 2 (Halls 500-700) on the following dates: 2/3/21, 2/4/21, 2/5/21, 2/6/21, 2/9/21, 2/11/21, 2/12/21, 2/15/21, 2/16/21, 2/17/21, 2/18/21, 2/21/21, 2/22/21, 2/23/21, 2/24/21, 2/27/21, 2/28/21, 3/1/21, 3/2/21, 3/5/21, 3/6/21, 3/7/21, 3/11/21, 3/12/21, 3/13/21, 3/14/21, 3/18/21, 3/19/21, 3/20/21, 3/25/21, 3/26/21, and 4/5/21. During an interview on 4/16/21 at 9:55 a.m., the SW said Resident #1 reported LVN H yelling and being threatening to her and the previous administrator on multiple occasions. The SW did not know when the yelling or threatening behaviors occurred, and she did not make any notes of the reports by Resident #1. The SW said she thought the previous DON knew about Resident #1's complaints. The SW said Resident #1 became fixated on things and on everything, and she exaggerated. The SW said she did not make notes or document Resident #1's complaints specifically because she was told the previous administrator was handling the complaints. The SW said she did not recall what Resident #1's complaints about LVN H were, but she remembered Resident #1 did not like LVN H and thought LVN H did not like her also. The SW said she completed satisfaction rounds with other residents and no other residents complained about LVN H. The SW said she did not interview staff regarding Resident #1's complaints against LVN H. Record review of Resident #1's nurse's note dated from 12/1/20 to 4/12/21 indicated she reported difficulty sleeping on 12/19/20, 12/21/20, 1/5/21, 1/29/21, 2/8/21, 2/10/21, 3/3/21, 3/4/21, 3/8/21, 3/9/21, and 3/15/21. Record review of Resident #1's nurse's note written by the current DON dated 4/6/21 at 3:30 p.m. indicated Resident #1 was upset about a staff member. The note indicated Resident #1 was asked if she had any injuries or had been hurt and Resident #1 denied having any injuries or being hurt. During an interview on 4/15/21 at 3:15 p.m., MA C said Resident #1 reported she was afraid of LVN H. MA C said Resident #1 reported she did not feel safe to sleep at night and did not sleep. MA C said Resident #1 slept with a cane for protection from LVN H. MA C said she reported Resident #1's complaints to the charge nurses, the previous DON, and the social worker. MA C said LVN H continued to work with Resident #1 and there were no interventions placed to protect Resident #1. MA C said she was not interviewed by the administrator or the facility regarding LVN H's behaviors towards residents. MA C said the administrator was the Abuse Preventionist. During an interview on 4/15/21 at 3:29 p.m., RN A said LVN H was verbally threatening to residents. RN A said LVN H's behaviors were reported to the previous DON. RN A said the previous DON blew off the allegations. RN A said she had reported LVN H's concerning behaviors to the previous DON and previous administrator and they both blew off the allegations. RN A said she was not interviewed by the administrator or the facility regarding LVN H's behaviors towards residents. RN A said the administrator was the Abuse Preventionist. During an interview on 4/15/21 at 5:32 p.m., the current DON said Resident #1 reported allegations of threatening behaviors against LVN H on 4/6/21 and LVN H was suspended immediately for half a day. The DON said the SW completed satisfaction rounds with other residents and found no concerns with LVN H. The DON said she did not interview staff or obtain written staff statements about how LVN H treated residents. The DON said the administrator was the Abuse Preventionist. During an interview on 4/15/21 at 6:09 p.m., the current administrator said he was the Abuse Preventionist. The administrator said during his investigation of the reports from Resident #1 of verbal threats by LVN H, staff were not interviewed regarding LVN H's demeaner or treatment of [REDACTED]. The administrator said he encouraged staff to be open with their communication and no staff had called him to report concerns regarding LVN H. During a telephone interview on 4/16/21 at 9:21 a.m., Resident #1 was interviewed regarding her allegations against LVN H. During the interview Resident #1 was very emotional, her voice was shaky, and she continued to express fear of Resident #1. Resident #1 said LVN H would stand at the foot of her bed some nights and yell at her for using her call light more than one time. Resident #1 said LVN H told her to only use her call light one time during the night. Resident #1 said LVN H yelled at her and made her cry. Resident #1 said she reported LVN H's behavior to the SW and the previous administrator. Resident #1 said that she did not feel safe at night and began sleeping with a wooden cane in her bed for protection. Resident #1 said she slept with a cane in her bed from approximately November 2020 to March 2021. Resident #1 said she could not sleep at night due to being so fearful. Resident #1 said she would not sleep on the nights LVN H worked due to fear. Resident #1 said an agency nurse, name unknown, witnessed LVN H yelling at her one night. Resident #1 said one night, date unknown, she had not received her pain medication and was afraid to ask. She said she finally built up enough courage to go ask LVN H for the medication. Resident #1 said LVN H yelled at her and told her to go to her room and she would not give Resident #1 her pain medication until she went to her room. Resident #1 said she called the previous administrator and reported LVN H and requested a CNA to be present when LVN H came into her room. Resident #1 was tearful and said she was really afraid of LVN H. Resident #1 said LVN H would make the CNA stand in the hallway outside of her room and made Resident #1 believe there was not a CNA present. Resident #1 said she reported multiple instances of LVN H's yelling and threatening behavior to the previous DON and previous administrator and LVN H continued to work with Resident #1. Resident #1 said she started to feel hopeless because when she told the previous DON and previous administrator nothing was done to protect her. Resident #1 said her family wanted to call the corporate staff, but she was afraid since nothing had been done to stop LVN H's behaviors. Resident #1 said when the new administrator came to the facility on an unknown date, she did not have the courage to tell him because of how her previous complaints had been blown off by the previous DON and previous administrator. Resident #1 said in April 2021 she finally had enough courage to tell the current DON her concerns about LVN H. Resident #1 said the administrator was notified and the police were called. Resident #1 said the next day after she reported LVN H to the current administrative staff, she felt like other staff (laundry and housekeeping) were treating her different. Resident #1 said that was one of the reasons she decided to move to another skilled nursing facility. Resident #1 said she felt relieved to be in a facility she did not have to worry about LVN H yelling at her and being threatening. Record review of an Abuse/Neglect policy updated on 11/7/16 indicated, .The resident has the right to be free from abuse .Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff .The facility will provide and ensure the promotion and protections of Resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse .mistreatment of [REDACTED]. The facility will determine the direction of the investigation based on a thorough examination of events .any person having reasonable cause to believe an elderly or incapacitated adult is suffering from abuse .must report this to the DON, administrator .employee will make an immediate verbal report to the Abuse Preventionist or designee .Comprehensive investigations will be the responsibility of the administrator and/or Abuse Preventionist. All allegations of abuse .will be investigated .The administrator in consultation with the risk management department will be responsible for investigating and reporting cases .After receipt of the allegation the Abuse Preventionist and administrator .will immediately evaluate the Resident's situation .With an allegation of abuse .the employee(s) will immediately be suspended pending an investigation .The Abuse Preventionist and/or administrator will conduct a thorough investigation of the incident(s) .The facility will take necessary measures to protect residents and employees from harm .following an abuse .all allegations will be investigated regardless of identification of caller . The administrator was notified on 4/16/21 at 10:03 a.m. that an Immediate Jeopardy situation was identified. The administrator was provided the Immediate Jeopardy template on 4/16/21 at 10:05 a.m. The facility's Plan of Removal was accepted on 4/16/21 at 6:15 p.m. and included: Interventions: One on One in-service on Abuse Investigation with the Administrator/DON; Staff working with Alleged perpetrator have been interviewed; Alleged perpetrator has been terminated; Resident safe surveys have been completed; The following in-services were initiated by the ADO and regional nurse on 4/16/21: Any staff member not present or in-serviced on 4/16/21, will not be allowed to assume their duties until in-serviced: All Staff Abuse/Neglect; Abuse/Neglect Reporting; and Who to Report Abuse/Neglect to The medical director was notified of the immediate jeopardy situation on 4/16/21 at 10:56 a.m. Monitoring Administrator to Investigate and submit findings to ADO and Risk Management for review Administrator will submit documentation of investigation with Resident and Staff interviews, as well as weekly follow up interviews with staff and residents x 4 weeks to ensure resident safety/satisfaction with outcome of investigation ADO will monitor weekly x 4 weeks documentation The QA committee will review findings monthly and makes changes as needed. Confirmation of the facility's implementation of their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) included: Interviews with seven LVNs, eleven CNAs (from all three shifts), one MA (on the 6 a.m. to 2 p.m. shift),four nurses on the weekend shifts (6 a.m. to 10 p.m. on Saturdays and Sundays); one housekeeper, three dietary staff, one MDS Nurse, the maintenance director, the ADON, the DON, and the administrator said they were in-serviced on abuse/neglect, reporting abuse/neglect, and who to report abuse/neglect to. They all said they would report all allegations of abuse/neglect to the DON and administrator. All staff interviewed said all allegations of abuse would be reported and would be taken seriously. Review of the alleged perpetrator's personnel file confirmed she was terminated. On 4/16/21 at 7:20 p.m., the administrator was informed the IJ was removed; however, the facility remained out of compliance at a severity level of actual harm that is not Immediate Jeopardy with a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan, 1 (Resident #2) of 5 residents reviewed for quality of care. The facility failed to ensure Resident #2 received the necessary care and services to address his diabetes. Resident #2 routinely had a blood sugar level below 70 and his levels were not rechecked to ensure they rose to an appropriate level. (Normal blood sugars levels are generally between 70 to 130 mg/ dl). On 03/23/21 Resident #2's was found unresponsive, his blood sugar level was 39, and he required interventions from emergency personnel to raise his blood sugar level. An Immediate Jeopardy (IJ) was identified at 9:00 a.m. on 4/16/21. While the IJ was removed on 4/16/21, the facility remained out of compliance a severity level of actual harm that is not Immediate Jeopardy and a scope of isolated due to the facility's ongoing evaluation of the effectiveness of the corrective systems. These failures resulted in an identification of an Immediate Jeopardy (IJ) at 9:00 a.m. on 4/16/21. While the IJ was removed on 4/16/21, the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems This failure could place residents as at risk of seizures, diabetic coma, or death. Findings included: The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The order stated to notify the physician for a blood sugar reading less than 70 The admission MDS dated [DATE] indicated Resident #2 was admitted to the facility on [DATE] from an acute care hospital. The MDS indicated Resident #2 understood others with clear comprehension and made himself understood. The MDS indicated Resident #2 had moderate cognitive impairment and had no behavior of rejecting care. The MDS indicated Resident #2 had an active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS indicated Resident #2 had no changes in his insulin orders during the 7 day look back period. The care plan initiated on 2/11/21 indicated Resident #2 had diabetes mellitus. The care plan interventions included administer diabetes medication as ordered by the doctor and monitor/document for side effects and effectiveness. The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The summary report indicated Resident #2 was discharged from the facility on 3/30/21. The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This order was in effect until 4/1/21. The vitals summary for February and March 2021 indicated Resident #2 had a blood sugar of less than 70 mg/dl (Milligrams per deciliter ) following dates and times; *2/25/21 at 7:13 a.m., FSBS (finger stick blood sugar) reading of 67; the blood sugar was not rechecked until 11:45 a.m.; *3/4/21 at 6:40 a.m., FSBS reading of 55; the blood sugar was not rechecked until 11:57 a.m.; *3/4/21 at 5:05 p.m., FSBS reading of 67; *3/5/21 at 7:02 a.m., FSBS reading of 56; the blood sugar was not rechecked until 11:46 a.m.; *3/6/21 at 11:52 a.m., FSBS reading of 60; the blood sugar was not rechecked until 6:06 p.m.; *3/10/21 at 5:40 a.m., FSBS reading of 69; the blood sugar was not rechecked on this day; *3/11/21 at 6:57 a.m., FSBS reading of 49; the blood sugar was not rechecked 11:20 a.m.; *3/12/21 at 7:16 a.m., FSBS reading of 46; the blood sugar was not rechecked until 11:16 a.m.; *3/14/21 at 8:16 a.m., FSBS reading of 67; the blood sugar was not rechecked until 1:44 p.m.; *3/22/21 at 7:09 a.m., FSBS reading of 49; the blood sugar was not rechecked until 11:31 a.m.; *3/23/21 at 12:29 a.m., FSBS reading of 56; the blood sugar was not rechecked until 10:44 a.m.; *3/23/21 at 10:44 a.m., FSBS reading of 39; *3/29/21 at 1:18 a.m., FSBS reading of 50; the blood sugar was not re-checked until 7:15 a.m.; and *3/29/21 at 7:15 a.m., FSBS reading of 42; the blood sugar was not rechecked until 11:30 a.m. The nursing notes for February 2021 -March 2021 did not indicate the physician had been notified regarding the blood sugar readings less than 70 mg/dl on the following dates and times; *2/25/21 at 7:13 a.m., FSBS reading of 67; *3/4/21 at 6:40 a.m., FSBS reading of 55; *3/4/21 at 5:05 p.m., FSBS reading of 67; *3/5/21 at 7:02 a.m., FSBS reading of 56; *3/6/21 at 11:52 a.m., FSBS reading of 60; *3/10/21 at 5:40 a.m., FSBS reading of 69; *3/11/21 at 6:57 a.m., FSBS reading of 49; *3/12/21 at 7:16 a.m., FSBS reading of 46; *3/14/21 at 8:16 a.m., FSBS reading of 67; *3/23/21 at 12:29 a.m., FSBS reading of 56; *3/23/21 at 10:44 a.m., FSBS reading of 39; *3/29/21 at 1:18 a.m., FSBS reading of 50; and *3/29/21 at 7:15 a.m., FSBS reading of 42. The nursing note dated 3/23/21 at 12:56 a.m., indicated Resident #2's blood sugar was 56 and a snack was given. The next nursing note dated 3/23/21 at 11:29 a.m., indicated Resident #2's blood sugar was 39 at 7:30 and he was unresponsive. The note indicated an emergency [MEDICATION(S)] injection and glucagel was administered and the blood sugar was 40 at 7:45 after the administration. The note indicated Emergency services were called and IV glucose was administered. The note indicated Resident #2's blood sugar 246 at 8:43 a.m. and he was provided a meal. The note did not indicate that the physician had been notified. The nursing note dated 3/23/21 at 9:20 pm indicated Resident #2 had vomited. The note did not indicate his blood sugar was checked. During an interview on 4/14/21 at 7:00 p.m. the former DON said she was sure the nurses had notified the medical director regarding his hypoglycemic episodes because she thought the medical director had decreased his insulin. During an interview on 4/15/21 at 2:00 pm, LVN E said she took care of Resident #2 often while he was at the facility. LVN E said she was sure she had notified Resident #2's physician regarding his many hypoglycemic incidents. LVN E said she was sure he told her to give Resident #2 something to eat. During an interview on 4/15/21 at 3:00 p.m., LVN M said she did not notify the physician during the hypoglycemic event that occurred on her shift because of how late it was. LVN M said she was sure she reported the event to the on-coming shift. LVN M said she thought she rechecked Resident #2's blood sugar later but could not say for sure. During an interview on 4/15/21 at 3:35 p.m., the DON said nurses should notify the physician if a FSBS is below the ordered parameters. The DON said nurses should recheck a FSBS after an intervention was provided for a low blood sugar. During an interview on 4/16/21 at 9:20 a.m., the medical director said he had been notified of one hypoglycemic event on 3/22/21. He said LVN E notified him Resident #2 FSBS was 49 but had improved after a snack. He said LVN E said the resident was not eating well. The medical director said he ordered a medication to stimulate Resident #2's appetite. The medical director said he was not notified of any additional hypoglycemic episodes. The medical director said if he would have been notified of repeated episodes he would have made changes to Resident #2's antidiabetic medication and insulin. The American Diabetes Association website accessed on 4/22/21 at https://www.diabetes.org/healthy-living/medication-treatments/blood-glucose-testing-and-control/[CONDITION(S)], stated Low blood sugar is when your blood sugar levels have fallen low enough that you need to [MEDICATION(S)] to bring them back to your target range. This is usually when your blood sugar is less than 70 mg/dL . The only sure way to know whether you are experiencing low blood sugar is to check your blood sugar, if possible. If you are experiencing symptoms and you are unable to check your blood sugar for any reason, treat the [CONDITION(S)] . Signs and symptoms of low blood sugar happen quickly. From milder, more common indicators to most severe, signs and symptoms of low blood sugar include: Feeling shaky; Being nervous or anxious; Sweating, chills and clamminess; Irritability or impatience; Confusion; Fast heartbeat; Feeling lightheaded or dizzy; Hunger; Nausea; Color draining from the skin (pallor); Feeling sleepy; Feeling weak or having no energy; Blurred/impaired vision; Tingling or numbness in the lips, tongue or cheeks; Headaches; Coordination problems, clumsiness; Nightmares or crying out during sleep; and Seizures. A low blood sugar level triggers the release of [MEDICATION(S)] (adrenaline), the fight-or-flight hormone. [MEDICATION(S)] is what can cause the symptoms of [CONDITION(S)] such as thumping heart, sweating, tingling and anxiety. If the blood sugar level continues to drop, the brain does not get enough glucose and stops functioning as it should. This can lead to blurred vision, difficulty concentrating, confused thinking, slurred speech, numbness, and drowsiness. If blood sugar stays low for too long, starving the brain of glucose, it may lead to seizures, coma and .death . The 15-15 rule-have 15 grams of carbohydrate to raise your blood sugar and check it after 15 minutes. If it's still below 70 mg/dL, have another serving. Repeat these steps until your blood sugar is at least 70 mg/dL. Once your blood sugar is back to normal, eat a meal or snack to make sure it doesn't lower again . The Mayo Clinic website accessed on 4/22/21 at https://www.mayoclinic.org/diseases-conditions/[CONDITION(S)]/symptoms-causes/syc- 685, stated .[CONDITION(S)] needs immediate treatment when blood sugar levels are low. For many people, a fasting blood sugar of 70 milligrams per deciliter (mg/dL), or 3.9 millimoles per liter (mmol/L) .Untreated [CONDITION(S)] can lead to; seizure; loss of consciousness; death .Over time, repeated episodes of [CONDITION(S)] can lead to [CONDITION(S)] unawareness. The body and brain no longer produce signs and symptoms that warn of a low blood sugar, such as shakiness or irregular heartbeats. When this happens, the risk of severe, life-threatening [CONDITION(S)] increases . The facility policy titled Glucometer, revised on 2/13/2007 stated, .Abnormal Results (1) Notify the physician if the blood glucose is outside of any physician specific parameters and implement any new orders prescribed . The administrator was notified on 4/16/21 at 10:03 a.m. that an Immediate Jeopardy situation was identified due to the above failures. The administrator was provided the Immediate Jeopardy template on 4/16/21 at 10:05 a.m. The facility's Plan of Removal was accepted on 4/16/21 at 6:15 p.m. and included: Interventions: 100% blood sugar audit by 5pm today by Administrative nurses and Corporate Compliance Nurse Physician will be notified of all blood sugars outside the parameters of scale by 5pm today. The following in-services were initiated 4/16/21 by Regional Compliance Nurse: Any nurse not present or in-serviced on 4/16/21 will not be allowed to assume their duties until in-serviced: Following facility policy for [CONDITION(S)] located in the Glucometer policy: Abnormal Results 1. Notify the physician if the blood glucose is outside of any physician specific parameters and implement any new orders as prescribed 2. If the resident has an order for [MEDICAL RECORD OR PHYSICIAN ORDER] 3. If no order for [MEDICATION(S)]: a. If the resident is responsive and can swallow, administer orange juice with sugar added or glucose gel b. If the resident is unresponsive notify emergency medical services. Notified Medical Director of IJ situation on 4/16/21 at 10:56am. Monitoring: DON/Designee will review 5-8 residents slide scale results for proper notification to MD if outside parameters weekly x 4 weeks. DON/Designee will monitor all blood sugars outside parameters of slide scale for notification to MD weekly x 4 weeks. Regional Compliance Nurse will DON/Designee for monitoring compliance weekly x 4 weeks. The QA Committee will review findings and Physician Notification Policy and will make changes as needed monthly. One 4/16/21 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Seven LVNs (on all shifts - 6 a.m. to 2 p.m.; 2 p.m. to 10 p.m.; and 10 p.m. to 6 a.m.); four nurses on the weekend shifts (6 a.m. to 10 p.m. on Saturdays and Sundays); one MDS Nurse; and the ADON said they were in-serviced on facility policy for [CONDITION(S)], established parameters for M.D. notification and prompt notification related to FSBS. Verification of 100% blood sugar audit by the administrative nurses and corporate compliance Nurse was completed. Residents with ordered parameters in place had the physician notified of blood sugars outside of ordered parameters. All diabetic residents had ordered parameters in place. On 4/16/21 at 7:20 p.m., the administrator was informed the IJ was removed; however, the facility remained out of compliance at actual harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review, the facility failed to provide necessary treatment and services, based on the comprehensive assessment and consistent with professional standards of practice, to promote healing and prevent development of pressure injuries for 2 of 5 residents reviewed for pressure injury. (Residents #2 and #4). The facility did not prevent, accurately assess, provide appropriate treatment, provide ordered treatment, provide recommended treatment, or notify the physician of Resident #2's pressure injuries. Infection of Resident #2's pressure injuries led to the amputation of Resident #2's right leg below the knee on 4/3/21. These failures resulted in an identification of an Immediate Jeopardy (IJ) at 9:00 a.m. on 4/16/21. While the IJ was removed on 4/16/21, the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at risk for the development of new or worsening pressure injuries, infection, hospitalization amputation or death. Findings included: The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The summary report indicated Resident #2 was discharged from the facility on 3/30/21. The admission MDS dated [DATE] indicated Resident #2 was admitted to the facility on [DATE] from an acute care hospital. The MDS indicated Resident #2 understood others with clear comprehension and made himself understood. The MDS indicated Resident #2 had moderate cognitive impairment. The MDS indicated Resident #2 had no behavior of rejecting care. The MDS indicated Resident #2 required extensive assistance with bed mobility, dressing, toilet use and personal hygiene. The MDS indicated Resident #2 was always incontinent of bowel and bladder. The MDS indicated Resident #2 had been assessed for pressure injury risk using a formal assessment instrument/tool (e.g., Braden, Norton, or other). The MDS indicated Resident #2 had no risk for developing pressure injuries. The MDS indicated Resident #2 had no pressure injuries. The discharge MDS dated [DATE] indicated Resident #2 had been discharged from the facility to the community on 3/30/21. The MDS indicated Resident #2 had no behavior of rejecting care. The discharge MDS indicated Resident #2 required extensive assistance with bed mobility, locomotion in his wheelchair, dressing, toilet use and personal hygiene. The MDS indicated Resident #2 required limited assistance with transfers and walking. The MDS indicated Resident #2 required physical help in part with bathing. The MDs indicated Resident #2 was always incontinent of bowel and bladder. The MDS indicated Resident #2 had two unstageable DTIs (deep tissue injuries) that were not present on admission. The care plan initiated on 3/1/21 indicated Resident #2 had DTIs (deep tissue injury) to his right and left heel. The care plan interventions included, assess/record/monitor wound healing at least weekly. The care plan interventions indicated CNAs were to report loose or missing dressings on the right heel to the nurse. Measure the wound length, width, and depth where possible. Assess and document the status of wound perimeter, wound bed and healing. Report declines to the medical doctor. During an interview on 4/13/21 at 11:37 a.m., Resident #2's family member said Resident #2 had a stroke in the beginning of February. The family member said when he was discharged from the hospital he went to facility for rehabilitation because the stroke had affected his left side. The family member said Resident #2 could move the left arm to some degree but not his left leg. The family member said on a visit she saw the pressure injuries and pointed them out to the facility staff. The family member said she was very upset and had a meeting with the facility over the pressure injuries. The family member said the facility tried to tell her Resident #2 had the pressure injuries when he got there. The family member said when Resident #2 was discharged from the facility on 4/30/21 she felt the wounds were infected and took him directly to his primary physician. The family member said at the primary physician's office pictures were taken of the wounds to document their condition. The family member said the primary physician sent her to the local emergency department due to the status of the wounds. The family member said the emergency room felt Resident #2 needed a higher level of care and sent him to another hospital. Resident #2 said within days of being at the second hospital Resident #2 had a below knee amputation to his right leg due to wound infection. Resident #2 said it was horrible that Resident #2 lost his leg but it was extremely horrible Resident #2 lost the leg that was not effected by his recent stroke. The medical records dated 3/30/21 from the primary physician's office documented with photographs the pressure injuries to Resident #2's the sacrum, right heel and left heel. There were also multiple DTIs to Resident #2's left and right toes. The emergency room provider notes dated 3/30/21 from the local emergency department indicated Resident #2 had pressure injuries to the left heel, right heel and sacrum. The emergency room provider notes documented these pressure injuries with photographs. The notes indicated Resident #2 was started on antibiotics due to infection in the heel wounds. The notes indicated Resident #2 would be transferred to a higher level of care for further management of the wounds. The infectious disease consult notes dated 4/1/20 indicated Resident #2 had focal [CONDITION(S)] (an infection and inflammation of the bone or the bone marrow. It can happen if a bacterial or fungal infection enters the bone tissue from the bloodstream, due to injury or surgery. Around 80 percent of cases develop because of an open wound) in the right foot. During an interview on 4/20/21 at 12:30 p.m., the infectious disease practitioner that treated Resident #2 during his hospitalization said she would speculate that the [CONDITION(S)] Resident #2 developed to the R foot was likely due to the pressure injury he developed to the right foot. The operative note dated 4/3/21 indicated Resident #2 had a right below knee amputation due to [CONDITION(S)]. The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This order was active until 4/1/21. The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This order was active until 4/1/21. The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This order was in effect until 2/19/21. The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This order was active until 3/16/21. The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This order was active until 4/1/21. The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The order stated the wound was to be cleansed with normal saline, patted dry, [MEDICATION(S)] gel applied, covered with a foam dressing and wrapped. This order was active until 3/23/21. The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This order was active until 4/1/21. The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The order stated the wound was to be cleansed with normal saline, patted dry, [MEDICATION(S)] gel applied, covered with a foam dressing and wrapped. This order was active until 4/1/21. The TARs (treatment administration records) for February 2021 indicated Resident #2 had not received any wound care from 2/19/21- 2/28/21. The TARs for March 2021 indicated Resident #2 had not received any wound care from 3/1/21- 3/11/21. The TARS for March 2021 indicated Resident #2 did not receive skin prep to the left heel as ordered on the following dates and shifts; * 3/16/21 on the p.m. shift; *3/19/21 on the a.m. shift; *3/20/21 on the a.m. shift; * 3/22/21 on the p.m. shift; *3/23/21 on the a.m. shift; and *3/25/21 on the p.m. shift. The TARS for March 2021 also indicated Resident #2 did not receive any wound care to the right heel as ordered on the following dates; *3/19/21 *3/20/21; and *3/23/21. The TARS for March 2021 also indicated Resident #2 did not receive wound care as recommended by the contracted wound care provider to the right and left heel from 3/19/21- 3/30/21. The initial weekly skin assessment dated [DATE] indicated Resident #2 had no pressure injuries. This assessment was signed by LVN E. The weekly skin assessment dated [DATE] stated Resident #2 had a soft area to left heel. This assessment was signed by LVN E. The weekly skin assessment dated [DATE] indicated Resident #2 had a DTI to the left heel that measured 3 centimeters by 6 centimeters (which measurement was length and which measurement was height was not specified). This assessment was signed by LVN E. The weekly skin assessment dated [DATE] indicated the DTI to Resident #2's left heel measured 4 centimeters by 4.5 centimeters. The skin assessment indicated Resident #2 had a newly identified DTI to the right heel, which measured 4 centimeters by 4 centimeters. Neither the left heel or the right heel measurements specified which measurement was length and which was height. This assessment was signed by LVN E. The weekly ulcer assessment for dated 3/10/21 indicated the DTI to Resident #2's right heel measured 4 centimeters in length, 4.5 centimeters in width, and had an undetermined depth. The assessment indicated the pressure injury was closed, had no drainage and no signs/symptoms of infection. This assessment was signed by LVN L. The weekly ulcer assessment for dated 3/10/21 indicated the DTI to Resident #2's left heel measured 4 centimeters in length, 4 centimeters in width, and had an undetermined depth. The assessment indicated the pressure injury was closed, had no drainage and no signs/symptoms of infection. This assessment was signed by LVN L. The weekly skin assessment dated [DATE] stated Resident #2 had DTI areas to the right and left heels, and toes on each foot. The skin assessment did not provide measurements for any of the DTIs. This assessment was completed by LVN E. The weekly skin assessment dated [DATE] indicated the DTI to Resident #2's right heel measured 4 centimeters by 4 centimeters and the DTI to his left heel measured 4 centimeters by 4.5 centimeters. Neither the left heel or the right heel measurements, specified which measurement was length and which was height. This assessment was completed by LVN E. The weekly ulcer assessment for dated 3/17/21 indicated the DTI to Resident #2's right heel measured 4 centimeters in length, 4 centimeters in width, and had an undetermined depth. The assessment indicated the pressure injury was closed, had no drainage and no signs/symptoms of infection. The assessment also indicate Resident was on an air mattress. This assessment was signed by LVN E. The weekly ulcer assessment for dated 3/17/21 indicated the DTI to Resident #2's left heel measured 4 centimeters in length, 4.5 centimeters in width, and had an undetermined depth. The assessment indicated the pressure injury was closed, had no drainage and no signs/symptoms of infection. The assessment also indicate Resident was on an air mattress. This assessment was signed by LVN E. The initial wound evaluation and management summary, completed by the wound care provider on 3/19/21 indicated Resident #2 had a shear wound to his right buttock that measured 2 centimeters in length, 1.5 centimeters in width and 0.1 centimeters in depth. The summary indicated Resident #2 had an unstageable DTI to the right heel that measured 7 centimeters in length, 7 centimeters in width and had depth that could be measured. The summary indicated Resident #2 had an unstageable DTI to his left heel that measured 6 centimeters in length, 7 centimeters in width and had depth that could be measured. The summary indicated Resident #2's wounds to both heels were debrided (remove damaged tissue from a wound). The summary indicated the wound care provider recommended all three wounds be treated with collagen powder, Anacept gel and have a foam silicone dressing applied. The weekly ulcer assessment dated [DATE] indicated the pressure injury to Resident #2's right heel measured 6 centimeters in length, 6 centimeters in width, and had an undetermined depth. The assessment classified the wound as other than ulcer. The assessment indicated the wound bed had 100 percent eschar (dead tissue that sheds or falls off from the skin. ) adhered to the wound bed. The assessment indicated there was slough (a white or yellow covering on the base of the wound can prevent a wound from healing properly) present and had a moderate amount of bloody liquefying necrotic tissue (partial or complete dissolution of dead tissue and transformation into a liquid, [MEDICATION(S)] mass). The assessment indicated there were no signs/symptoms of infection. This assessment was signed by LVN E. The weekly ulcer assessment dated [DATE] indicated the pressure injury to Resident #2's left heel measured 6.5 centimeters in length, 8 centimeters in width, and had an undetermined depth. The assessment classified the wound as other than ulcer. The assessment indicated the wound bed had 100 percent eschar adhered to the wound bed. The assessment indicated there was a light amount of bloody liquefying necrotic tissue. The assessment indicated there were no signs/symptoms of infection. This assessment was signed by LVN E. The wound evaluation and management summary, completed by the wound care provider on 3/26/21 indicated Resident #2 had a shear wound to his right buttock that measured 10centimeters in length, 0.6 centimeters in width and 0.2 centimeters in depth. The summary indicated Resident #2 had an unstageable DTI to the right heel that measured 6.5 centimeters in length, 6 centimeters in width and had depth that could be measured. The summary indicated Resident #2 had an unstageable DTI to his left heel that measured 6.5 centimeters in length, 6 centimeters in width and had depth that could be measured. The summary indicated Resident #2's wounds were debrided. The summary indicated the wound care provider recommended all three wounds be treated with collagen powder, Anacept gel and have a foam silicone dressing applied. The weekly ulcer assessment for dated 3/26/21 indicated Resident #2 had a new Stage 2 pressure injury to his left buttock that measured 0.5 centimeters in length, 1 centimeter in width and 0.1 centimeter in depth. The note titled, Skin/Soft Tissue Infection or [CONDITION(S)], dated 3/30/21 at 12:10 a.m. indicated Resident #2 had an infection to both of his heels. The note indicated the heels were tender, swollen and red. The note indicated Resident #2 had been placed on an antibiotic. This note was signed by LVN E. The note titled, Skin/Soft Tissue Infection or [CONDITION(S)], dated 3/30/21 at 9:45 a.m. indicated Resident #2 had an infection to both of his heels. The note indicated the heels had brown and bloody discharge. The note indicated Resident #2 had been placed on an antibiotic. This note was signed by LVN E. The nursing notes from 2/11/21 to 3/30/21 did not indicate the medical doctor had been notified of Resident #2's development/worsening of pressure injuries. During an interview on 4/13/21 at 11:37 a.m., Resident #2's family member said Resident #2 had a stroke in the beginning of February. The family member said when he was discharged from the hospital he went to facility for rehabilitation because the stroke had affected his left side. The family member said Resident #2 could move the left arm to some degree but not his left leg. The family member said on a visit she saw the pressure injuries and pointed them out to the facility staff. The family member said she was very upset and had a meeting with the facility over the pressure injuries. The family member said the facility tried to tell her Resident #2 had the pressure injuries when he got there. The family member said when she had to take him home on 4/30/21 she felt the wounds were infected and took Resident #2 to his primary physician. The family member said at the primary physician's office pictures were taken of the wounds to document their condition. The family member said the primary physician sent her to the local emergency department due to the status of the wounds. The family member said the emergency room felt Resident #2 needed a higher level of care and sent him to another hospital. Resident #2 said within days of being at the second hospital Resident #2 had a below knee amputation to his right leg due to wound infection. During an interview on 4/14/21 at 1:10 p.m., Resident #2 said during his stay at the facility, the nurses treated his heels maybe 4 or 5 times total. He said they put iodine on his heels. Resident #2 said he never refused to put his legs on a pillow and he never refused treatment to his heels. During an interview on 4/14/21 at 7:00 p.m. the former DON said she was not notified by any nurse that the DTIs Resident #2 developed at the facility had gotten larger or worse in condition. The DON said Resident #2 refused to keep heels floated while in bed. The former Don said the facilities previous wound care nurse left in March and at that time she got the wound care provider to come to the facility to manage wounds at the facility. The former DON said she thought Resident #2 was placed on a low air loss mattress within 15-20 days of his admission. The former DON said she told the nurses Resident #2's pressure injuries would have to be classified as DTIs but later the DTI's ruptured and the wound care practitioner started seeing him. During an interview on 4/15/21 at 1:00 p.m. LVN L said she thought Resident #2 had wounds on his feet. LVN L said she did not recall performing a wound or skin assessment on Resident #2. LVN L said she may have performed an assessment but could not remember for sure. During an interview on 4/15/21 at 1:43 p.m., CNA F said Resident #2 would let her float his heels. CNA F said she never had any issues with Resident #2 refusing to have heels floated. CNA F said he would occasionally refuse to lay on his side but was generally compliant. CNA F said she was not sure if he was on a low air loss mattress. During an interview on 4/15/21 at 2:00 pm, CNA K said she took care of Resident #2 often while he was at the facility. CNA K said Resident #2 did not come to the facility with wounds. CNA K said Resident #2 never refused to have his heels floated. CNA K said she felt not everyone took the time to float his heels. CNA K said Resident #2 told her she was the only one who floated his heels. CNA K said she took care of Resident #2 for a few days when he was on the 800 hall. CNA K said while he was on the 800 hall the wounds were not open. CNA K said Resident #2 then moved to the 700 hall and that is when she saw the wounds to Resident #2's heels were draining excessively. CNA K said she would frequently have to change Resident #2's bed linens because the wounds soaked the linens with bloody looking drainage. CNA K said sometimes Resident #2 had dressings to the heels and sometimes he did not. CNA K said when he did have dressing to the heels they were often saturated. CNA K said she would report the saturated dressing to LVN K because she knew it was not good. CNA K said when she would get Resident #2 up for showers the wounds would drip all over the floor. CNA K said she repeatedly reported to LVN E the wounds were draining excessively. CNA K said LVN E would just tell her his wound care had already been done and there was nothing she could do. CNA K said she noticed Resident #2 seemed to be getting new wounds on his toe knuckles and reported them to the nurse as well. CNA K said the wounds just seemed to be getting worse. CNA K said Resident #2 did not have a low air loss mattress until he had been moved to the 100 hall. The census record indicated Resident #2 had been on hall 800 from 2/11/21 until 3/1/21. The census record indicated Resident #2 was on the 700 hall from 3/1/21 to 3/17/21 and was then on the 100 hall from 3/17/21 until discharge. During an interview on 4/15/21 2:30 p.m. LVN E said she notified the former DON that the wounds were getting worse. LVN E said she thought she notified the physician of Resident #2's wounds were getting worse. LVN E said she never really rounded with the wound care physician to hear what he said about the wounds. LVN E said Resident #2 would refuse to float his heels. LVN E said occasionally therapy would notify her that Resident #2's dressing needed to be changed and she changed them. LVN E said Resident #2 had daily dressing changes when the wounds started draining. LVN E said if she did not have time to complete wound care on her shift the on-coming shift would perform the care. During an interview on 4/15/21 at 3:30 p.m. the wound care provider said he had only recently started seeing residents at the facility. The wound care provider said he did not see Resident #2 until 3/19/21. The wound care provider said it was not appropriate for the resident not to receive treatments for the DTIs from 2/19/21 to 3/11/21. The wound care provider said appropriate interventions for unopened DTIs would be offloading the heels and applying skin prep. The wound care provider said the roll of skin prep applied to DTIs was to help [NAME] the skin. He said it was not appropriate to put skin prep on draining wounds. The wound care provider said the roll of collagen powder applied to wounds was to facilitate the healing process. The wound care provider said the facility failing to put collagen powder on the wounds as recommended would not likely contribute to infection but could delay the healing process. The wound care provider said missing wound care altogether could increase the risk of wound infection. During an interview on 4/16/21 at 9:20 a.m., the medical director said he had been notified regarding the wounds on the 3/25/21 and was told the Resident was seeing the wound care provider for management of the wounds at that time. The medical director said he could not say he had been notified of the wounds prior to the 3/25/21. The medical director said he had not been notified Resident #2's wounds were getting larger/worse in condition. 2. The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] indicated Resident #4 sometimes made herself understood and sometimes understood others. The MDS indicated Resident #4 had severely impaired cognitive function. The MDS indicated Resident #4 had no behavior of rejecting care. The MDS indicated Resident #4 required extensive assistance with bed mobility, transfers, dressing, and personal hygiene. The MDS indicated Resident #4 was totally dependent on staff for locomotion in her wheelchair, eating, and toilet use. The MDS indicated Resident #4 was always incontinent of bowel and bladder. The MDS indicted Resident #4 was at risk for pressure injury development and had one unhealed pressure injury. The MDS indicated Resident #4 had one unstageable DTI present upon readmission to the facility. The care plan revised on 3/10/21 indicated Resident #4 had a DTI to her right heel. The care plan interventions included administer treatments as ordered. The TAR for April 2021 indicated Resident #4 did not receive wound treatment as ordered on the following dates; *4/6/21; *4/8/21; *4/10/21; and *4/13/21. During an interview on 4/15/21 at 3:35 p.m., the DON indicated that there had been a problem identified with skin assessments and wound care. The DON said she had just not had time to fully form/implement corrective actions. The website http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/ accessed 11/10/19 indicated the following . Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 1 Pressure Injury: Non-blanchable [CONDITION(S)] of intact skin Intact skin with a localized area of non-blanchable [CONDITION(S)], which may appear differently in darkly pigmented skin. Presence of blanchable [CONDITION(S)] or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [CONDITION(S)] (IAD), intertriginous [CONDITION(S)] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, [CONDITION(S)], abrasions). Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epiboly (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION(S)] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions . The facility policy revised 8/12/16, titled Pressure Injury: Prevention, Assessment, and Treatment, stated, (1) Nursing personnel will continually aim to maintain the skin integrity, tone, turgor and circulation to prevent breakdown, injury, and infection. (2) Early prevention and/or treatment is essential upon initial nursing assessment of the condition of the skin on admission and whenever a change in skin status occurs. The nurse will determine if prevention and /or treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . (3) Upon assessment and identification of a pressure sore the staff nurse will notify the treatment nurse/designee. The treatment nurse/designee will: (1) Notify the physician of pressure sore and obtain and follow any orders as directed by the physician .Deep Tissue Injury: Persistent non-blanchable deep red, maroon or purple discoloration. Intact or non-intact skin with localized are of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION(S)] separation revealing a dark wound bed or blood filled blister. Unstageable Pressure Injury: Obscured full thickness skin and tissue loss, Full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a stage 3 or Stage 4 pressure injury will be revealed. (7) Nursing Care Plan (1) Identify the problem of pressure injuries on the nursing care plan. (2) Under nursing interventions list the physician ordered treatments. (3) Staging definitions recognize the following limitations . (when necrosis is present accurate staging of the pressure injury is not possible until the necrosis has sloughed or the wound has been debrided .Assessment of the pressure injury should include the site, size and W (width)x L (length) and D (depth), of the injury. Surrounding tissue, color, exudate, wound edges, [MEDICATION(S)] tracts, odor, tunneling and undermining should also be documented at least weekly and upon decline. The administrator was notified on 4/16/21 at 10:03 a.m. that an Immediate Jeopardy situation was identified due to the above failures. The administrator was provided the Immediate Jeopardy template on 4/16/21 at 10:05 a.m. The facility's Plan of Removal was accepted on 4/16/21 at 6:15 p.m. and included: Interventions: 100% skin rounds completed by 5pm today (4/16/21) by Administrative Nurses and Corporate Compliance Nurses The following in-services were initiated by Regional Compliance Nurse on 4/16/21: Any nurse not present or in-serviced on 4/16/21 will not be allowed to assume their duties until in-serviced. Licensed Nurses Pressure ulcer prevention and treatment including providing treatment as ordered and Initialing/Dating dressing. Documentation and Accurate Assessment of Pressure Ulcers If a C.N.A reports to a charge nurse about a change in skin integrity/wound status, the charge nurse must assess and notify MD of changes immediately. Notification of Physician with change of condition immediately. The medical director was notified of the immediate jeopardy situation on 4/16/21 at 10:56am Monitoring: The DON / designee will view each wound weekly x 4 weeks. The DON / [TRUNCATED]

Based on observation, interview and record review the facility failed to ensure an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections for 2 of 10 staff reviewed for infection. (CNA E and LVN C) The facility did not protect residents from exposure to COVID-19 when they allowed CNA E who had been exposed to COVID-19 to work in the facility. LVN C did not wear a facemask properly at all times while in the facility. An Immediate Jeopardy (IJ) situation was identified on 12/7/2020. While the IJ was removed on 12/9/2020, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for exposure to COVID-19, health complications, and death. Findings included: During an interview on 12/4/2020 at 1:45 p.m., the administrator said the facility currently had 22 COVID-19 positive residents and 13 positive staff members. The administrator said staff at the facility were being tested twice weekly due to the current COVID-19 positivity rate in the county. The administrator said they had not had any COVID-19 positive residents until 11/23/2020 when 5 residents on the back side of the 400-hall tested positive for COVID-19. He said on 11/25/2020 PCR testing was done for all residents minus the 5 positive residents and a quick COVID-19 test was done on all staff members. He said 2 additional residents were found to be COVID-19 Positive. One of the positive residents resided at the end of the 400 hall and one on the 500 hall. The administrator said on 11/28/2020 the facility tested the weekend staff and 3 were positive, residents were tested and 4 were positive. The residents who tested positive on 11/28/2020 resided on the upper end of 400 and one resided on the 500 hall. He said on 11/30/2020 the facility tested 57 staff 4 were positive. He said on 11/30/2020 3 residents tested positive in the facility and 1 tested positive at the doctor's office. Those residents resided at the end of the 400 hall and 2 on hall 500 and one on the 800 hallway. During an interview on 12/7/2020 at 10:55 a.m., CNA F said she worked the 400 hall with an aide that was out for a while after testing positive for COVID-19. She the aide was exposed to her husband who tested positive for COVID-19 and was not quarantined correctly and exposed residents at the facility to [MEDICAL CONDITION]. She said a few weeks later residents on the 400 hallway began to test positive for COVID-19. During an interview on 12/7/2020 at 11:30 a.m., an unidentified staff member, said there was talk at the facility about a CNA who worked on the 400 hall who was sick with COVID-19 after being exposed to her spouse who also tested positive for COVID-19. The unidentified staff member said the aide told administration that she had been exposed to COVID-19 but was told to work anyway when the rapid test came back negative. The unidentified staff member said the aide was not sent home to quarantine until the PCR COVID-19 test came back positive. The unidentified staff member said the facilities outbreak began on the 400 hallway. During an interview on 12/7/2020 at 2:05 p.m., CNA E said she was exposed to her husband who tested positive for COVID-19 on 11/3/2020. CNA E said that on 11/4/2020 she reported to the DON that she had been exposed to her husband who tested positive for COVID-19. She said the DON gave her a rapid test which came back negative, then a PCR (a lab technique called polymerase chain reaction) test and told her it was okay to work. CNA E said she worked on 11/5/2020. She said on 11/6/2020 she reported to the director of nursing that she did not have a fever, sore throat or shortness of breath but did not feel herself, she felt very sluggish. She said again she was given a rapid test which was negative and allowed to work in the facility wearing PPE. CNA E said on 11/7/2020 her COVID-19 PCR ( a lab technique called polymerase chain reaction) test was positive, and she was then placed on a 14-day quarantine. CNA E said she knew she should not have worked after being exposed to COVID-19 and she felt as though it was her fault the residents had caught [MEDICAL CONDITION], and some had passed away. During an interview on 12/7/2020 at 2:20 p.m., the DON said if a staff member reported they had been exposed to someone who tested positive for COVID-19 they would be immediately sent home to quarantine for 14 days. The DON said she knew why she was being asked this question and the CNA did not say her husband tested positive for COVID-19, she only said he had been tested because of exposure. The DON said the staff member had not had a PCR test done at the facility. The DON said she was not aware the CNA's husband had tested positive for COVID-19 until 11/7/2020 when the CNA's test came back positive. The DON said if staff are showing symptoms of COVID-19, are positive for COVID-19 or are exposed to COVID-19 they are to be immediately sent home to quarantine for 10-14 days. During an interview on 12/7/2020 at 2:50 p.m., the administrator said staff should quarantine if they had a positive COVID-19 test, if they exhibited symptoms of COVID-19 and have a fever, and on a case by case basis. He said if a staff member was exposed to someone exhibiting symptoms of COVID-19 or had been diagnosed with [REDACTED]. The administrator said if the rapid test was positive the staff member would be sent home to quarantine. He said if there was any question regarding if the staff member should work he would contact the corporate nurses for direction. During an interview on 12/7/2020 at 4:20 p.m., CNA E said she was always screened upon entry to the building and she incorrectly answered the screening questions from 11/4/2020-11/6/2020 regarding exposure because she was told to work her shift by the director of nurses. During an interview on 12/7/2020 at 3:02 p.m., RN D said staff should quarantine for 10-14 days if they had been exposed to COVID-19 or had tested positive for COVID-19. She said if a staff member reported they had been exposed to someone they live with who is showing symptoms of COVID-19 or had tested positive for COVID-19 the staff member should be sent home to quarantine for 14 days. RN D said even if the staff member who had been exposed tested negative on the rapid test they would still be sent home to quarantine for 14 days. During a record review the facilities staffing schedules dated 11/2/2020-11/6/2020 indicated, CNA E cared for residents on the 1,2,3 and 400 hallways on the 6-2 a.m. shift. During a record review an undated/untitled facility log indicated, CNA E tested positive for COVID-19, her last day of work was 11/6/2020, returned to work on 11/19/2020 and that she had been expected to quarantine for 14 days. During a record review a facility policy dated 7/18/2020, titled Risk Assessment and work restrictions for Healthcare personnel with Potential or confirmed exposure dated 7/7/2020 indicated if a person had an exposure to a person with COVID-19 who had symptoms (in the period from 2 days before symptom onset until they meet criteria for discontinuing home isolation; can be laboratory confirmed or a clinically compatible illness (suspected)); a person who has tested positive for COVID-19 (laboratory confirmed) but has not had any symptoms ( in the 2 days before the date of specimen collection until they meet criteria for discontinuing home isolation) should stay home until 14 days after the last exposure and maintain social distancing (at least 6 feet apart) from others at all times and self-monitor for symptoms including checking temperature twice a day and to watch for fever, cough, shortness of breath or other symptoms of COVID-19. The policy indicated when the health care provider lived in a household where they could not avoid contact with the person who had COVID-19 (suspected or positive), they must remain quarantined during patient's x10 plus day isolation, plus 14 day. The administrator was notified on 12/7/2020 at 4:56 p.m. that an IJ situation was identified due to the above failure. The administrator was provided the IJ template on 12/7/2020 at 5:09 p.m. The facility's Plan of Removal was accepted on 12/8/2020 at 7:49 p.m. and included: Interventions: The following in-services were initiated by the DON, ADON and regional nurse on 12/7/20: Any staff member not present or in-serviced on 12/7/20, will not be allowed to assume their duties until in-serviced. o Staff will be in-service on the following in-services with a completion date of 12/8/20 and as needed thereafter In-service staff on Infection Control Overview In-service staff on proper PPE use in the facility in-service staff on CDC recommendations for quarantine after exposure to Covid-19 Any staff that have a known exposure to Covid-19 will be immediately quarantined per CDC guidelines. Administrator and DON were in-serviced on CDC recommendations for quarantine after exposure to Covid-19, Infection Control and PPE use by the Area Director of Operation and the Corporate Compliance Nurse on 12/7/20 The medical director was notified of the immediate jeopardy situation on 12/7/20 at 6:03pm Monitoring The DON / designee will observe PPE use by randomly selecting 10 staff members weekly on various shifts x 4 weeks The QA committee will review findings and infection control policies and makes changes as needed on 12/8/20 and as needed thereafter The Administrator and or DON will be notified immediately if any staff has had a known exposure to Covid-19 and will ensure the staff member does not return to work until criteria has been met to discontinue precautions per CDC guidance on 12/8/20 On 12/08/2020 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: 7 LVNs (on all shifts - 6 a.m.- 2 p.m., 2 p.m.- 10 p.m., 10 p.m.-6 a.m. and 8 a.m.-5 p.m.) and 7 CNA's from all shifts 6 a.m.- 2 p.m., 2 p.m.- 10 p.m., 10 p.m.-6 a.m.), 4 housekeeping and laundry staff and 1 dietary aide said they received training regarding infection control, proper PPE to wear at all times while inside the facility, CDC recommendations for quarantine post exposure to COVID-19. All staff said if they were exposed to COVID-19 they would immediately report the exposure to the DON and administrator and would begin quarantine for 14 days. The DON and administrator said they received training regarding proper quarantine procedure for staff exposure to COVID-19. They said that for the next 4 weeks they would be randomly selecting 10 staff members on various shifts and would observe how they are wearing, donning and doffing PPE. On 12/9/2020 at 9:40 a.m., the administrator was informed the IJ was removed; however, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. Non-Immediate Joepardy findings included: During an observation on 12/4/2020 at 1:30 p.m., LVN C came to the front door to greet surveyor without a facemask on. During an observation on 12/7/2020 at 9:30 a.m., LVN C was in her office with 3 other employees present and the door open without a facemask on. During an interview on 12/7/2020 at 3:35 p.m., LVN A said the facilities policy regarding facemasks was that the facemask must be worn at all times while in the facility. During an interview on 12/7/2020 at 3:37 p.m., LVN C said a facemask was to be worn at all times while in the facility. During an interview on 12/7/2020 at 3:40 p.m., the DON said a facemask must be worn by staff at all times while inside the facility unless eating or drinking. During an interview on 12/7/2020 at 3:50 p.m., CNA B said she had been performing visitor screening at the entrance of the building and that all PPE (mask, gown and face shield/ goggles) must be donned upon entry and worn at all times while in the facility. During an interview on 12/7/2020 at 3:55 p.m., the administrator said staff were to wear a mask at all times while in the facility unless in designated break areas for eating and drinking. During a record review an undated facility policy titled PPE use when positive COVID residents are in the facility indicated that while in a cool zone all staff must wear a gown, gloves (when providing direct care), N95 if available, if not a surgical mask. The policy indicated that while in a warm zone all staff must wear a gown when providing care to a resident, gloves when providing direct care to a resident and a face shield and eye protection when providing direct resident care. The facility indicated that while in a HOT zone all staff should wear a gown, gloves, N95 and face shield or eye protection.

Based on interview and record review, the facility failed to ensure assistance devices to prevent accidents were provided for 1 of 3 residents reviewed for transfers. (Resident #1) The facility did not evaluate Resident #1's transfer needs, develop a transfer care plan and provide Resident #1 with a safe transfer. CNA A and CNA C transferred Resident #1 without using an appropriate transfer device. Resident #1 sustained a spiral fracture (a fracture that occurs when a long bone is broken by a twisting force) of the distal femoral diaphysis (area of the long leg bone just above the knee joint). This failure could place residents who required assistance with transfers at risk for discomfort, pain and injury. Findings included: Physician orders [REDACTED].#1 was [AGE] years old, admitted [DATE], and had [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #1 understood others, was understood and had severely impaired cognition. The MDS indicated the resident was totally dependent (full staff performance every time) on 2 staff for transfers. A care plan dated 3/26/2020 indicated Resident #1 had impaired cognitive function. The care plan indicated Resident #1 was at risk for falls and had a history of [REDACTED].#1 had an ADL self-care deficit and required assistance of staff with ADL's. The care plan did not address Resident #1's needs for transfer assistance. A nursing note dated 3/25/2020 at 9:09 p.m. indicated the nurse was called to Resident #1's room around 8:30 p.m. Resident #1's right knee was rotated inward touching her left knee and her right leg was turned out. Her right foot was swollen with 2+ [MEDICAL CONDITION] (swelling that indents with pressure). The nurse was unable to palpate a pedal pulse (located on top of the foot). The note indicated the resident's right heel was a dark purple/blue color. The note indicated the physician was notified and the resident was sent to the ER. An x-ray dated 3/25/20 indicated Resident #1 had a displaced right spiral [MEDICAL CONDITION] femoral diaphysis. During an interview on 3/27/2020 at 5:12 p.m., CNA A said Resident #1 was confused and occasionally had behaviors and would resist care. CNA A said Resident #1 was a two-person extensive assist to transfer. CNA A said Resident #1 could bear weight some days. She said they transferred the resident by the mechanical lift on some days and some days they would transfer her with 2 people. She said they normally used the gait belt when they transferred her, but that evening on 3/25/20, she did not have a gait belt with her. She said Resident #1 was not able to bear weight during the transfer on 3/25/20. CNA A said Resident #1 did not have a lift pad under her and they were already in the process of transferring her so, they just lifted her up and finished the transfer. CNA A said she assisted CNA C to transfer Resident #1 to her bed from the wheelchair around 3:00 p.m. CNA A said they grabbed Resident #1 under her arms and by the seat of her pants and transferred her to the bed. CNA A said they did not use the gait belt to transfer Resident #1. CNA A said Resident #1 complained of her hip hurting when she was in the bed. She said this was common for Resident #1 after she had been sitting up in the wheelchair for a while. CNA A said she reported to the charge nurse the resident was complaining of pain. CNA A said she checked on the resident several times after lying her down and she was fine. CNA A said she went with CNA C to change Resident #1 around 8:30 p.m. and Resident #1 complained of her hip hurting. She said she looked at her leg at that time and her knee was twisted in and her right heel was purple and black. During an interview on 3/27/20 at 4:49 p.m., CNA C said Resident #1 was a 2 person assist with transfers. She said Resident #1 could bear weight. CNA C said they always used a gait belt when transferring Resident #1. She said on 3/25/20, Resident #1 was not feeling well and wanted to lie down. She said she assisted CNA A with transferring Resident #1 from her wheelchair to her bed at approximately 3:00 p.m. CNA C said they transferred Resident #1 from the wheelchair to the bed without incident. She said they used the gait belt and Resident #1 was able to stand and pivot. CNA C said Resident #1 complained of nausea and being sore. She said Resident #1 complained of pain frequently after sitting in the wheelchair for an extended amount of time, so this was normal for her. CNA C said she checked Resident #1 after dinner. She said Resident #1 did not eat because she felt nauseated. She said she did not complain of pain at that time. CNA C said she went in to check Resident #1 at approximately 8:30 p.m. and her right leg was turned in and her foot was discolored. CNA C said Resident #1 cried out in pain when she tried to move her leg and she reported it to LVN B. During an interview on 3/27/20 at 6:22 p.m., LVN B said Resident #1 was confused and was not able to stand. She said Resident #1 was weight bearing as tolerated. LVN B said she had not observed staff transfer Resident #1 on 3/25/20. She said they had been transferring her using the mechanical lift and believed they still used the mechanical lift occasionally. LVN B said she came into work around 6:00 p.m. on 3/25/20. She said Resident #1 was in bed with no complaints. She said she checked the resident's blood sugar around 8:00 p.m. and Resident #1 still had no complaints of pain. She said CNA C reported the resident had a discolored foot around 8:30 p.m. LVN B said she assessed Resident #1 and her right knee was rotated in and her lower leg was rotated out. She said her right foot was swollen and her heel was dark blue/purple. LVN B said she notified the physician immediately and sent Resident #1 to the emergency room for further evaluation. During an interview on 3/27/20 at 5:52 p.m., The DON said staff did not complete an incident report when Resident #1 was sent to the hospital on [DATE]. She said she did not know why an incident report was not completed. The DON said she was not aware CNA A and CNA B transferred Resident #1 without a gait belt. She said she expected her staff to use the gait belt during transfers. The DON said Resident #1 was able to bear weight and should be transferred with the assistance of 2 staff. She said staff should use a gait belt when transferring Resident #1. The DON said Resident #1 did not have an order to be transferred by mechanical lift. https://www.osha.gov/ergonomics/guidelines/nursinghome/final_nh_guidelines.html accessed on 3/31/20 indicated . a resident requires an assessment of their needs and abilities when determining the safest methods for a transfer. The resident assessment should include the level of assistance the resident requires; the size and weight of the resident; the ability and willingness of the resident to understand and cooperate .when a patient is unable to bear weight and is unwilling or unable to assist with a transfer, a full body sling and 2 caregivers should be used for transfers from bed to chair or chair to bed .

Based on interview and record review, the facility failed to ensure the right to be free from abuse was provided for 1 of 5 residents reviewed for abuse. (Resident #1) The facility did not prevent NA [NAME] from verbally abusing Resident #1. NA [NAME] told Resident #1 you can lay in bed and rot for all I care. NA [NAME] took Resident #1's pillows off her bed and threw them on the floor and stated, if you want your pillows you can get them yourself, making Resident #1 cry and causing mental anguish. This failure could place residents who were dependent upon staff for care at risk for abuse. Findings included: Physician orders [REDACTED].#1 was [AGE] years old, was admitted [DATE] with [DIAGNOSES REDACTED]. The physician orders [REDACTED]. The most recent MDS dated [DATE] indicated Resident #1 was usually understood and usually understands others, had severely impaired cognition and had no behaviors during the assessment period. The MDS indicated Resident #1 required total assistance performing bed mobility, locomotion on and off the unit, eating, toileting, personal hygiene and bathing. The assessment indicated she required extensive assistance with transfers and dressing. The MDS indicated Resident #1 did not walk during the assessment period and was always incontinent of bowel and bladder. A care plan dated 8/21/19 indicated Resident #1 was at risk for falls due to impaired cognition and left sided weakness. Interventions included to keep personal and frequently used items within reach and to remind her not to walk or transfer without assistance. The care plan indicated Resident #1 had difficulty making herself understood due to her cognitive impairment. Interventions included to ask her to repeat slurred, mumbled words and to praise her when spoken words are distinct and intelligible. During an observation and interview on 9/25/19 at 10:18 a.m., Resident #1 was in bed and responded to all questions with short yes and no answers. Resident #1 responded no when asked if NA [NAME] treated her with respect and dignity. She responded yes when asked if NA [NAME] was rude to her and made her cry. When Resident #1 was asked what happened with the pillows, she removed the pillow from under her head and gestured throwing it on the floor. Resident #1 responded yes when asked if NA [NAME] hurt her feelings and yes it made her feel bad and made her cry. During a telephone interview on 9/25/19 at 11:17 a.m., CNA D said on 8/29/19 she was in Resident #1's room with NA E. She said Resident #1 was in her wheelchair and NA [NAME] told her you can walk, get up and walk. CNA D said she told NA [NAME] Resident #1 could not walk and she should not be talking to the resident rudely. CNA D said NA [NAME] told the resident you can lay in your bed and rot for all I care. CNA D said on 8/30/19 around 1 p.m., she and NA [NAME] were in Resident #1's room to transfer her to bed. She said NA [NAME] told Resident #1 you can walk, and you know it, I am tired of you telling everyone you can't walk. CNA D said Resident #1 began crying and NA [NAME] told her go ahead and get in the bed so you can rot. CNA D said NA [NAME] removed Resident #1's pillows off the bed and threw them in the floor and told Resident #1 if you want your pillows, you can get up and get them yourself. CNA D said she transferred Resident #1 to bed herself and placed the pillows where the resident liked them to be placed. She said NA [NAME] got angry and left the room. CNA D said she told Resident #1 she would report NA [NAME] to the DON and she would ask her not to assign the CNA to care for her again. During an interview on 9/25/19 at 1:13 p.m., the DON said NA [NAME] was fired because of the incident with Resident #1. She said there were accusations NA [NAME] was rude to Resident #1 and an investigation was done. The DON said CNA D reported NA [NAME] threw Resident #1's pillows on the floor and talked rudely to her. The DON said she did not remember if it was reported NA [NAME] told Resident #1 she could rot in bed. The DON said she did not do the investigation and was not sure of the outcome. She said she would consider the allegation to be abuse and it should have been reported to state office. The DON said NA [NAME] was short and abrasive with residents. During an interview on 9/25/19 at 1:51 p.m., the administrator said on 8/30/19 the human resource staff (no longer employed) reported Resident #1 fell while NA [NAME] was in the resident's room and she did not report the fall to the nurse. The administrator said during the investigation the CNAs (unable to recall names) told him NA [NAME] told residents I will wait on you when I get ready. The administrator said he did not consider this abuse or neglect because he was told she took care of the resident afterwards. The administrator said CNA D reported NA [NAME] was rude to Resident #1. He said he could not remember what CNA D said NA [NAME] did to Resident #1. He said he could not remember if he spoke to Resident #1 regarding the allegations. He said his investigation ruled out abuse and he told the DON to contact NA [NAME] to come in and answer follow up questions. The administrator said the DON notified NA [NAME] on 9/3/19 and requested she come in to discuss the investigation. The administrator said it was not intended to terminate NA E, but she was rude when the DON called her, and because she was in her 90-day probation period, she was terminated. An Abuse - Reportable Events policy revised (MONTH) 2019 indicated: It is the responsibility of all facility staff to prohibit resident abuse and neglect, exploitation and misappropriation of resident's property in any form .

Based on interview and record review facility failed to promptly notify the physician of laboratory results 1 of 2 residents reviewed for laboratory services (Resident #1). The facility did not notify the physician of Resident #1's PT/INR ([MEDICATION NAME] Time/International Normalized Ratio) elevated results for 3 weeks. Resident #1's was admitted to the hospital with [REDACTED]. This failure could place 2 residents who received PT/INR labs at risk of bleeding, blood clots, and/or death. Findings included: An undated face sheet indicated Resident #1 was [AGE] years old and admitted on [DATE] with [DIAGNOSES REDACTED]. A care plan dated 02/05/18 indicated Resident #1 was at risk for bleeding due to taking an anticoagulant. The care plan indicated [MEDICATION NAME] was discontinued and the physician would determine if Resident #1 was a candidate for Xarelto. A pharmacy recommendation dated 02/12/18 indicated Resident #1 had an order for [REDACTED]. The physician signed the pharmacy recommendation on 02/22/18. The DON signed the pharmacy recommendation on 03/05/18. A physician order [REDACTED].#1 was ordered PT/INR to be drawn weekly for 4 weeks, then monthly. A nursing note dated 03/01/18 indicated Resident #1 received a new order for PT/INR to be drawn weekly for 4 weeks, then to draw monthly. PT/INR laboratory test results dated 03/02/18 indicated Resident #1's INR was 1.6 (reference range 0.8-1.2). An INR between 2.0-3.5 may be desired in patients taking [MEDICATION NAME] therapy. There was no documentation on the results page that the physician was notified of the results. Nursing notes dated 03/01/18 through 03/23/18 indicated no documentation that the physician was notified of Resident #1's PT/INR results. PT/INR laboratory test results dated 03/09/18 indicated Resident #1's INR was 1.5 (reference range 0.8-1.2). There was no documentation on the results page that the physician was notified of the results. Nursing notes dated 03/01/18 through 03/23/18 indicated no documentation that the physician was notified of Resident #1's PT/INR results. An order clarification dated 03/12/18 indicated Resident #1's [MEDICATION NAME] was discontinued. PT/INR lab dated 03/16/18 indicated Resident #1's INR was 1.7 (reference range 0.8-1.2). There was no documentation on the results page that the physician was notified of the results. Nursing notes dated 03/01/18 through 03/23/18 indicated no documentation that the physician was notified of Resident #1's PT/INR results. A nursing note dated 03/21/18 at 5:20 p.m., indicated Resident #1 was found unresponsive by the ADON. The resident moaned and answered yes/no questions very weakly. The head of bed was elevated and oxygen placed on resident. Resident #1 told the ADON that he could not breathe very well. His blood pressure was 127/49, pulse 90, respirations 28, and oxygen saturation 85%. His oxygen saturation went up to 97% after he was placed on oxygen. EMS was called. Hospital records dated 03/21/18 indicated Resident #1 had bilateral [MEDICAL CONDITION] embolisms. Hospital laboratory test records dated 03/21/18 at 6:45 p.m., indicated Resident #1's PTT (Partial [MEDICAL CONDITION] Time) was 44.8 (normal range 23.5-36.3 seconds), PT 19.1 (normal range 11.4-15.3 seconds), and INR 1.5 (normal range 0.8-1.2 seconds). Resident #1 was started on a [MEDICATION NAME] drip. During an interview on 03/23/18 at 3:47 p.m., Resident #1's physician said he did not recall the facility notifying him of any of Resident #1's INR results from (MONTH) (YEAR). He said he remembered, Resident #1's INR results were running high. He said if a resident was at risk of [MEDICAL CONDITION] embolism, his INR should be between 2.0-3.0. Resident #1's physician said Resident #1 was currently in the hospital with blood clots in his lungs. Resident #1's physician said he thought Resident #1 was going to be put on Xarelto but there was a miscommunication with staff. He said it was unlikely Resident #1 would have developed a [MEDICAL CONDITION] embolism if he was placed on Xarelto. During an interview on 03/23/18 at 4:49 p.m., LVN A said Resident #1's physician had a book at the nursing station containing laboratory test results for the physician to see. LVN A said the physician normally signed the laboratory test result after he reviewed it and it was placed in the resident chart. LVN A said if the physician was called about a laboratory test result, a nursing note would be documented in the resident chart that the physician was notified. During an interview on 03/23/18 at 5:39 p.m., LVN B said lab results were placed in the physician's book at the nursing station. She said the physician signed the lab sheet once he reviewed it, and then it is placed in the resident's chart. She said if a nurse notified the physician of a lab, it would be documented in the nursing notes of the resident. During an interview on 03/23/18 at 2:31 p.m., the DON said she expected nurses to follow-up on laboratory test results to ensure the physician was notified of the results. A facility laboratory order policy dated (MONTH) (YEAR) indicated .the attending physician will be notified promptly of lab results . During an interview on 03/23/18 at 2:31 p.m., the DON said 2 residents received PT/INR laboratory test monitoring.

Based on observation, interview, and record review, the facility failed to ensure 1 of 7 residents reviewed for medication accuracy was free from significant medication errors. (Resident # 1) The facility did not ensure Resident #1 received his daily [MEDICATION NAME] for his [MEDICAL CONDITION]. Resident # 1 did not receive [MEDICATION NAME] for 6 weeks, causing him to hear voices. This failure could place 40 residents with a psychiatric [DIAGNOSES REDACTED]. Findings included: Physician orders [REDACTED].#1's previous facility indicated Resident #1 received [MEDICATION NAME] 200 mg daily. A Medication Administration Record (MAR) dated 06/01/17 to 06/29/17, from Resident #1's previous facility indicated Resident #1 received [MEDICATION NAME] 200 mg daily. admission orders [REDACTED]. Physician orders [REDACTED].#1 was [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #1 usually made his needs known and usually understood others. Resident #1 required supervision with ADLs. Active [DIAGNOSES REDACTED]. The MDS indicated Resident #1 received an antidepressant medication, but no antipsychotic medication. During an interview on 08/23/17 at 2:03 p.m., LVN A said he was the admitting nurse for Resident #1 on 06/30/17. He said when he transcribed the physician orders [REDACTED].#1's medications. He said the doctor signed the orders once he (LVN A) transcribed them. He said he must have missed Resident #1's [MEDICATION NAME] order. LVN A said he should have included all Resident #1's medications in the physician admission orders [REDACTED]. A psychological service progress note dated 08/03/17 indicated Resident #1 was referred for psychological services due to his history of hospitalization from psychiatric concerns and current isolative behaviors. Resident #1 had a history of [REDACTED]. Resident #1's past [DIAGNOSES REDACTED]. Resident #1 said he had some trouble sleeping and his mother's condition remained his only source of anxiety. Resident #1 said he had not received his his antipsychotic medications. He said he had not experienced paranoia or hallucinations during this admission to the facility. He said he attended facility activities including church and found it personally engaging. During an interview on 08/23/17 at 9:21 a.m., LVN B said Resident #1 did not exhibit paranoid behaviors and did not hear voices from his admission on 06/30/17 until 08/09/17. During an interview on 08/23/17 at 11:42 a.m., the treatment nurse said from 06/30/17 to 08/09/17, Resident #1 showed no paranoid behaviors. During an interview on 08/23/17 at 2:48 p.m., LVN C said from 06/30/17 to 08/10/17, Resident #1 did not hallucinate and did not exhibit paranoid behaviors. She said up until 08/09/17, Resident #1 socialized with staff and residents. She said on 08/09/17, Resident #1 became reclusive and began exhibiting paranoia. A nursing note for Resident #1 dated 08/09/17 at 12:15 p.m. indicated staff was called into resident's room by the MA. The resident was noted to be very fidgety and unable to focus. The note said Resident #1 said he felt weird and was hearing voices. Resident would not say what the voices were telling him. Resident's mother was his roommate and the mother said the resident was not right and she could not get him to settle down. During an interview on 08/23/17 at 9:21 a.m., LVN B said on 08/09/17, Resident #1 was not acting right, not getting out of bed, not eating, and the resident said he was hearing voices. She said Resident #1 did not tell her what the voices were telling him. She did not notice any hallucinogenic behaviors until that day. She said she reported the abnormal behavior to the DON and was told to contact the NP. She said the NP ordered the resident to be sent to a behavioral hospital. She said the social worker attempted to find placement at several behavioral hospitals with no success. She said Resident #1 continued hearing voices and told the social worker that the voices told him to harm himself and others. A nursing note for Resident #1 dated 08/09/17 at 2:30 p.m. indicated the nurse spoke with NP and received an order to send Resident #1 to the behavioral hospital. A psychological service progress note dated 08/10/17 indicated Resident #1 had a flat affect, appeared disheveled, and was in bed. The progress note indicated Resident #1's eyes were wide open and would dart from place to place, but remained unfocused. Resident #1 agreed with the statement that he was hearing voices. Resident #1 would not say what the voices were telling him. Resident #1 stared at the television even when the television was off. During an interview on 08/23/17 at 11:42 a.m., the treatment nurse said she went into Resident #1's room on 08/10/17 to perform a skin assessment. She said Resident #1 was lying in bed with a devilish grin on his face and a blank stare in his eyes. She said she did not feel safe in the room with the resident. She said she left the room and reported the behavior to the social worker. Nursing notes for Resident #1 indicated the following: *08/10/17 at 12:30 p.m.-walked into resident's room to do skin assessment and noted resident's mental status to be considerably different. Resident would not answer questions, appeared to have a devilish grin on his face. Resident's eyes were wild and vacant. Resident was drawing a skeleton on his leg. This nurse did not feel comfortable being alone with resident; *08/10/17 at 4:00 p.m.-resident in bed and would answer questions with hmmm. Resident did not have a verbal conversation with the nurse; During an interview on 08/23/17 at 2:48 p.m., LVN C said Resident #1 was normally a social person that would stay out of his room most of the day. She said on 08/10/17, Resident #1 was not eating, not getting out of bed, and was not answering questions verbally. She said Resident #1 would make a grunting sound when asked a question. She said Resident #1 was staring into space and she felt that he could be a danger to himself or to his mother, who was his roommate. She said his mother said she was concerned about her son, but would not say if she feared him. A social worker progress note dated 08/10/17 indicated Resident #1 had increasing behaviors and paranoia. Resident #1 nodded his head yes when asked if he was hearing voices. Resident #1 nodded his head yes when asked if the voices were telling him to harm himself or others. Resident #1 was agreeable to go to the hospital to get help. During an interview on 08/23/17 at 12:21 p.m., the social worker said she was asked to visit with Resident #1 on 08/10/17 due to increased behaviors. She said Resident #1 would not answer questions verbally, but did answer questions with nodding his head. She said Resident #1 nodded his head yes when asked about hearing voices and the voices told him to hurt himself or others. She said Resident #1 was willing to go to a behavioral hospital. She said she attempted to find placement at several inpatient behavioral hospitals and was unable to find a hospital that would take him. She said Resident #1 was sent to theER on [DATE]. Nursing notes for Resident #1 indicated the following: *08/10/17 at 6:30 p.m.-behavioral hospital unable to take resident; *08/10/17 at 8:00 p.m.-resident taken to ER by EMS for evaluation, resident was still hearing voices but could not say what the voices were saying; Hospital records dated 08/10/17 indicated Resident #1 was seen in the ER and would not answer questions. Resident #1 would shrug shoulders or grunt to questions. Resident #1 had not made an effort to eat. Resident #1 appeared to have a difficult time understanding what was being asked of him. Behavioral hospital placement could not be found and it was recommended that Resident #1 did not need placement at this time. Resident #1 would be returned to the facility. A nursing note for Resident #1 dated 08/11/17 at 6:00 p.m., indicated Resident #1 returned to the facility and a new order was received for [MEDICATION NAME] 25 mg twice a day for [MEDICAL CONDITION]. During an interview on 08/23/17 at 9:21 a.m., LVN B said Resident #1 was sent to theER on [DATE] and returned to the facility on [DATE] and was started on [MEDICATION NAME] 25 mg twice a day. She said Resident #1 improved since starting on [MEDICATION NAME]. She said Resident #1 was on [MEDICATION NAME] 200 mg at his previous facility, but did not receive it when he was admitted on [DATE]. Nursing notes dated 08/14/17 at 12:45 p.m. indicated Resident # 1 laid in bed most of the shift, and did not eat lunch. The resident continued to hear voices but would not say what the voices were telling him. MA reported that she had to coach the resident on how to take his medications. During an interview on 08/23/17 at 2:21 p.m., the NP said Resident #1 should not have been abruptly stopped on his [MEDICATION NAME] when he admitted to the facility. She said Resident #1 probably would not have had hallucinations of hearing voices if the [MEDICATION NAME] 200 mg was not stopped. A Medication Administration Record for August 2017 indicated Resident #1 started [MEDICATION NAME] 25 mg twice a day on 08/12/17. During an observation and interview on 08/23/17 at 11:57 p.m., Resident #1 was lying in his bed covered with a sheet and his room was dark. Resident #1 was clean and free of odors. He said he was no longer hearing voices in his head. He said he was feeling better since getting his medications corrected. During an interview on 08/23/17 at 3:03 p.m., the DON said the facility did not have a policy on how physician orders [REDACTED]. She said her expectation was that the admitting nurse would use the previous facility's most current MAR and transcribe admitting orders and this did not happen with Resident #1. She said she felt the nurses may have exaggerated some about Resident #1's behaviors. According to www.drugsbd.com, last accessed 08/23/17, .[MEDICATION NAME] (Quetiapine) is a medication commonly prescribed to patients with [MEDICAL CONDITION] or [MEDICAL CONDITION] disorder. If not properly discontinued, [MEDICATION NAME] can cause very serious withdrawal symptoms [MEDICATION NAME] Withdrawal Symptoms - [MEDICATION NAME] helps to stabilize brain chemistry by blocking the chemical receptors of serotonin, [MEDICATION NAME] and adrenergic. The brain becomes used to having a high level of these natural chemicals within the brain at all times. If [MEDICATION NAME] is stopped abruptly the receptors are no longer blocked and there is a quick alteration in the balance of chemicals within the brain. Though [MEDICATION NAME] is unlikely to be abused, many patients' bodies become used to the effects of [MEDICATION NAME] and essentially become addicted. The symptoms that come with [MEDICATION NAME] withdrawal are because of the chemicals being used and finding a new balance within the brain Each body and brain is different and therefore the symptoms each patient may experience when withdrawing from [MEDICATION NAME] may be different. Common withdrawal symptoms are: nausea, headache, anxiety, excessive crying, nervousness, [MEDICAL CONDITION], symptoms of [MEDICAL CONDITION], depression, and mania. The CMS 672 dated 08/23/17 indicated 40 residents had a psychiatric diagnosis.

Based on observations, interviews and record reviews, the facility failed to provide adequate supervision and intervention to prevent accidents for 7 of 15 residents reviewed for accidents. (Resident #s 6, 8, 9, 16, 17, 18 and 19) Staff did not assess Resident #6 for safety to handle hot liquids. Resident #6 sustained second degree burns to his right chest and side from a hot coffee spill. Staff did not identify and assess the ability to handle hot liquids for Resident #s 9, 16, 17, and 18, and did not implement interventions to prevent potential accidents from hot liquids. Resident #19 and 8 said the coffee was served hot. This failure could place 15 residents who drank coffee in open cups at risk for burn injuries. Findings included: 1. An undated face sheet indicated Resident #6 was [AGE] years old, admitted [DATE], and re-admitted [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] indicated Resident #6 usually understands and was usually understood by others. He required extensive assistance with dressing and personal hygiene with the help of 1 person. The most recent care plan dated 1/21/16 indicated Resident #6 had a [DIAGNOSES REDACTED]. The care plan indicated Resident #6 required assistance during meals and would be assisted with tray set up, verbal cueing, and feeding as needed. An incident report dated 6/29/16 indicated Resident #6 spilled coffee and received burns to his right upper chest and right side. The incident report indicated the physician was notified and an order for [REDACTED]. The nursing notes dated 7/2/16 indicated there were several fluid filled blisters on Resident #6's right side near his hip. The nursing notes dated 7/2/16 indicated the blister was open and measured 3.6 centimeter (cm) x 3.5 cm. A Handling of Hot Liquids Safety Evaluation dated 6/29/16 (after the incident) indicated Resident #6 was unsafe to drink hot liquids if unsupervised. The evaluation indicated Resident #6 required additional interventions and needed a cup with a lid. During an observation and interview on 7/5/16 at 11:29 a.m., Resident #6 was in his room sitting upright in bed. His breakfast tray was on the bedside table and his coffee was in a cup with a lid. Resident #6 said he burned himself with his coffee over the weekend. He said he was in his room eating breakfast and picked up his coffee cup. He said his hand was weak and he bumped the cup on his bedside table. Resident #6 said he was wearing an undershirt and spilled the coffee on his right side. He said the burns were very painful. During an interview on 7/6/16 at 11:13 a.m., RN E said Resident #6 had been capable of drinking hot coffee safely. She said he drank coffee every day. She said on 6/29/16 she walked into Resident #6's room and he was holding the right side of his chest. She said he was grimacing and told her he spilled his coffee. RN E said Resident #6 was assessed for handling hot liquids safely after he received the burn and was now being provided a cup with a lid for hot beverages. RN E said all residents were not assessed for safety of handling hot liquids. She said residents were only assessed if there was a concern. She said residents with tremors, weakness, dementia or Parkinson's would be considered high risk residents. A coffee temperature log indicated the coffee was 160 degrees on 6/29/16, the day Resident #6 was burned. 2. An undated face sheet indicated Resident #16 was [AGE] years old, admitted [DATE] and re-admitted [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] indicated Resident #16 usually understands and was usually understood by others. He required limited assistance with the help of 1 person for eating. The most recent care plan dated 4/7/16 indicated Resident #16 had a [DIAGNOSES REDACTED]. The care plan indicated Resident #16 required assistance during meals and would be assisted with tray set up, verbal cueing, and feeding as needed. During an observation on 7/7/16 at 7:45 a.m., Resident #16 was eating breakfast in the dining room. Resident #16 had a slight tremor to his hand when he drank coffee from a cup. There was no lid on Resident #16's coffee cup. During an interview on 7/7/16 at 7:52 a.m., Resident #16 said the coffee was always hot. He said he liked it hot, but he often had to let it cool off before drinking it. The entire clinical records for Resident #16 contained no Handling of Hot Liquids Safety Evaluation. 3. An undated face sheet indicated Resident #17 was [AGE] years old and admitted [DATE] with [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #17 rarely understands and was rarely understood by others. She required limited assistance with the help of 1 person for eating. The most recent care plan dated 4/7/16 indicated Resident #17 had a [DIAGNOSES REDACTED]. The care plan indicated Resident #17 required assistance during meals and would be assisted with tray set up, verbal cueing, and feeding as needed. The entire clinical records for Resident #17 contained no Handling of Hot Liquids Safety Evaluation. During an observation on 7/7/16 at 7:48 a.m., Resident #17 was in the dining room for breakfast. She was drinking coffee from a cup without a lid. Resident #17 was being assisted by a staff member. The staff member left the resident alone at the table while she retrieved items for her tray. During an interview on 7/7/16 at 10:30 a.m., the dietician said the coffee temperatures were correct per facility policy. She said coffee was not palatable below 135 degrees. She said she realized burns could occur with the 160 degree coffee, but nursing had an assessment tool to help identify high risk patients. She said she did not know if the Handling of Hot Liquids Safety Evaluation was done on all residents. During an interview on 7/7/16 at 1:55 p.m., LVN D said he did not have a list of the residents at risk for handling hot beverages. During an interview on 7/7/16 at 2:06 pm., LVN J said she did not have a list of residents at risk for handling hot beverages. She said not all residents were screened for safety of handling hot beverages. She said residents were only screened if there was a concern. 3. Physician orders [REDACTED].#9 was [AGE] years old, admitted [DATE], with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #9 could understand others and made herself understood. Resident #9 required supervision with set up in all ADLs except bathing, where she needed extensive assistance of one person. During an observation on 7/6/16 at 8:30 a.m., Resident #9 was having breakfast in the dining room. Resident #9 had hand tremors and had to hold her coffee cup with both hands to prevent the coffee from spilling out of the coffee cup while drinking. The entire clinical record for Resident #9 contained no Handling of Hot Liquids Safety Evaluation. 4. During an observation on 7/7/16 at 7:35 a.m., two coffee pump pots were in the main dining room near the kitchen entrance, and were accessible to the residents. Twelve residents were drinking coffee in the dining room. 5. The MDS dated [DATE] indicated Resident #18 was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. Resident #18's assessment indicated she usually understood others and usually made herself understood. She required supervision and set up assistance with eating. During an observation on 7/7/16 at 7:40 a.m., Resident #18 was drinking coffee in the dining room with her right hand. Resident #18's left arm and hand were limp on the left side of her wheelchair. During an interview on 7/7/16 at 8:45 a.m., Resident #18 said she continued to have weakness in her left hand, arm and leg. She said she could use her left hand slightly, but sometimes used her right hand to assist her left hand and arm. Resident #18 said she drank coffee, but denied her coffee being too hot. 6. During an interview on 7/7/16 at 8:00 a.m., Resident #19 said his coffee was often real hot, but would rather have it hot than cold. During an interview on 7/7/16 at 8:10 a.m., Resident #8 was finishing his breakfast. He said his coffee was often very hot, but he would let it sit awhile before he drank it. During an interview on 7/7/16 at 11:00 a.m., the DON said they did not routinely assess residents for safety for hot liquids. She said they screened residents who they considered at risk. The DON said residents she considered to be at risk for spilling hot liquids included residents with a [DIAGNOSES REDACTED]. She said residents with weakness after a stroke could be at risk, depending on their weakness and said she could see potential safety concerns. The DON said she did not have a list of residents that were considered at risk for injury with hot liquids. She said Resident #6 did receive an assessment for hot liquid safety, but the assessment was completed after he spilled his coffee and was injured. She said residents had the right to have hot coffee. During an interview on 7/7/16 at 2:30 p.m., the FSS said the dietary staff did not have a list of residents who were at risk of injury with hot liquids. She said she was only aware of two residents who required special glasses for hot liquids, which included Resident #6. She said in the past she knew residents were screened by the speech therapist for safety with hot liquids, but was unsure who screened residents currently. The FSS said the coffee was temped at 160 degrees F, when placed in the pump pots and made available to any resident who drank coffee. During an interview on 7/7/16 at 2:45 p.m., LVN G said the charge nurses did not have a list of residents at risk for injury from hot liquids. She said she worked at both nursing stations and only knew of two residents who required special hot beverage cups with lids. LVN G said one of the two residents was Resident #6. She said the department heads screened and evaluated the residents for hot liquids. A Precautions for Hot Beverages policy dated January 2016 indicated .the facility shall monitor, serve and hold hot beverages in a safe manner to prevent potential burns .hot beverages will be monitored regularly and individualized by the clientele served .all efforts to prevent splashing of the liquid should be made, including the use of lids and special containers to prevent burns to either resident or staff .estimated time to receive a second degree burn with hot liquid at 150 degrees is less than 1 second .assessing and identifying those individuals served who are at high risk for burning themselves with hot beverages .ensuring staff monitor the identified high risk residents when hot liquids are served . utilizing special spill proof lids and insulated cups for those individuals identified as high risk for spillage and potential for burning .do not allow individual residents to take hot liquids from the dining room without a tight fitting lid . During an interview on 7/7/16 at 2:30 p.m., the FSS said she was not certain how many residents drank coffee, but she thought about 15.

Based on observation, interview, and record review, the facility failed to provide care and services in accordance with the comprehensive assessment to maintain the highest practicable, physical, mental, and psychosocial well-being for 1 of 7 residents reviewed for pain. (Resident #10) The facility did not provide pain relief for Resident #10, who had penile excoriation and swelling. This failure could place 40 residents who received scheduled and as needed (PRN) pain medication at risk of unresolved pain. Findings included: Physician orders [REDACTED].#10 was [AGE] years old, readmitted [DATE] with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #10 had severe cognitive impairment. He usually made self- understood and sometimes understood others. He required extensive assistance with most ADLs. He required limited assistance eating. Resident #10 had a [MEDICAL CONDITION]. A care plan dated 5/13/16 indicated Resident #10 had an altered thought process and Resident #10 was at risk for skin breakdown related to incontinence, impaired bed mobility, history of pressure ulcers, cognitive impairment and dementia with a goal .skin will remain clean, dry, and intact without evidence of breakdown . The care plan indicated Resident #10 had pain management with a goal of .having pain controlled and maintained at a tolerable level, if not successfully diminished, and show a decrease in number of pain episodes . The approach was to . evaluate verbal, nonverbal cues to assess pain severity, monitor for decrease in function, behavior changes, and anxiety; document changes, and report significant changes to physician; administer [MEDICATION NAME]/anti-inflammatories as ordered; assess effectiveness of medications and document same . A physician order [REDACTED].#10 to emergency room for penile bleeding and [MEDICAL CONDITION]. A comprehensive pain assessment form for Resident #10 dated 5/20/16 indicated: .Have you had pain or hurting in the last 5 days? Yes .; .What relieved the pain? Medication .; .Manner of expressing pain? Non-verbal, facial expressions, protective body movements, verbal complaints .; .Worst pain in the past 5 days? pretty bad . A physician order [REDACTED]. And a new order was received for a urinary analysis with culture sensitivity (UA C&S) testing if indicated due to penile discharge. A physician order [REDACTED].#10 indicated to discontinue the order to .cleanse tip of penis with normal saline (excoriation) apply A&D ointment twice a day . A physician order [REDACTED].#10 could receive Tylenol 325 mg 2 tablets by mouth every 4 hours for pain. A physician order [REDACTED].#10 indicated to .cleanse the penis with normal saline, then apply A&D ointment around foreskin/penal head every 8 hours, until able to retract foreskin . A physician order [REDACTED].#10 indicated new order for [MEDICATION NAME] 50 milligrams (mg) 1 tablet by mouth every 6 hours as needed for pain. A physician order [REDACTED].#10 indicated new order to .discontinue cleanse penis with normal saline then apply A&D ointment around foreskin/penal head until able to retract foreskin every 8 hours. Start new order flush head of penis with NS and pat dry every shift . A nursing note dated 7/1/16 at 10:00 a.m., written by LVN F indicated CNAs reported .inability to retract Resident #10's foreskin to perform pericare. Attempted to retract foreskin with lubrication, unable to retract foreskin safely . A nursing note dated 7/3/16 indicated the following: 8:00 a.m., indicated Resident #10 was yelling out help. 9:00 a.m., continued to yell out 11:00 a.m., resident has been yelling out all morning 3:30 p.m., physician was notified of increase in pain and new order was written for [MEDICATION NAME] A nursing note dated 7/4/16 indicated the following: 8:30 a.m., indicated Resident #10's feet and penis were hurting 12:00 p.m., continue to have inability to retract foreskin of penis. A pain assessment for the month of July 2016 indicated Resident #10 complained of pain the nights of 7/3/16, 7/4/16 and 7/5/16, but was not medicated for pain. The MAR indicated [REDACTED]. The treatment record for Resident #10 dated July 2016 indicated he received treatment to his penis every shift from 7/1/16 to 7/6/16 for a total of 17 treatments. Resident #10 received 17 treatments to cleanse penis with NS then apply A&D ointment around foreskin and penile head until able to retract foreskin every 8 hours. The EMAR (electronic medication administration record) dated July 2016 indicated Resident #10 was administered [MEDICATION NAME] pain medication on 7/3/16 at 5:00 p.m., 7/4/16 at 8:20 a.m., 7/5/16 at 6:15 a.m., 7/6/16 at 5:50 p.m. During an observation and interview on 7/5/16 at 3:33 p.m., Resident #10's foreskin appeared excoriated, and red. CNA H said for the past 4 days he was unable to retract Resident #10's foreskin without hurting him. Resident #10 said his penis was sore when CNA H touched it. CNA H did not notify or offer to notify the nurse. During an observation and interview on 7/7/16 at 10:55 a.m., RN E explained to Resident #10 that CNA K would be cleaning his penis. Resident #10 said, it hurts, be careful. CNA K said she did not clean the resident's penis thoroughly because it hurt the resident when she attempted to retract the foreskin. RN E said the resident was unable to say if he needed pain medication. RN E did not offer medication. During an interview on 7/7/16 at 11:28 a.m., RN E said CNA K stopped cleaning Resident #10's penis during pericare, because she knew it hurt him. She said Resident #10's penis hurt him all the time. RN E said residents should be medicated before painful procedures. RN E did not offer or give medication. During an interview on 7/7/16 at 2:41 p.m., RN E said she did not medicate Resident #10 today before providing pericare with CNA K. During an interview on 7/6/16 at 10:16 a.m., CNA L said Resident #10's penis was swollen for a week and had a blister on the end of it. She was unable to retract his foreskin to provide good peri care. She said Resident #10 complained his penis hurt when she tried to clean it. CNA L said she reported this to LVN F. CNA L said LVN F and RN E tried to clean Resident #10's swollen penis and were unable to retract his foreskin. During an interview on 7/6/16 at 10:20 a.m., LVN F said Resident #10 complained of his penis burning and hurting since he returned from his hospital stay on 5/17/16. She said [MEDICATION NAME] helped and she noticed Resident #10 did not holler out as much when he was medicated. She said he seemed much calmer with the [MEDICATION NAME]. LVN F administered [MEDICATION NAME] on 7/4/16 at 8:20 a.m., 7/5/16 at 6:15 a.m., 7/6/16 at 5:50 p.m. During an interview on 7/6/16 at 4:10 p.m., CNA M said since Resident #10's surgery in May 2015, she had not been able to retract his foreskin. She said she thought she would physically hurt him if she tried. She said she reported this to the charge nurse. During an interview on at 4:15 p.m., CNA N said she had not been able to retract Resident #10's foreskin for approximately 1 week. She said when Resident #10 urinated he said, Oh God, [MEDICAL CONDITION] I do that. She said she reported this to the charge nurse. During an interview on 7/6/16 at 4:20 a.m., LVN G said she worked with Resident #10 since mid-May 2016, and had never been able to retract his foreskin during incontinent care. She said Resident #10 had several urinary tract infections since May 2016 and his penis had become red and swollen over the last couple of days. LVN G said LVN F noticed Resident #10's penis was swollen on 7/5/16 and reported it to her at shift change. LVN G said last week Resident #10's daughter said he was complaining that he had a sore on his penis. LVN G said Resident #10's penis was excoriated and he complained that it burned when he urinated. LVN G said she did not offer Resident #10 pain medication prior to care. During an interview on 7/6/16 at 4:30 p.m., RN E said Resident #10's foreskin had always been hard to retract. She said he had a history of [REDACTED]. She said during the past few days while providing pericare, Resident #10 complained he hurt. RN E said Resident #10 was medicated with PRN medication. During an interview on 7/7/16 at 10:45 a.m., CNA L said Resident #10 complained his penis hurt when they tried to retract his foreskin. She said the staff did not attempt to retract his foreskin and clean it due to the pain it caused him. She said she reported Resident #10's complaints of pain to her charge nurse, but did not know if they medicated him. During an interview on 7/7/16 at 10:53 a.m., CNA K said she had not been able to retract Resident #10's foreskin for weeks. She said he had a red, open, area to the tip of the foreskin. CNA K said if she tried to retract Resident #10's foreskin he complained that it hurt. She said when Resident #10 complained of pain during pericare she stopped and notified the nurse. During an interview on 7/7/16 at 11:26 a.m., LVN F said she medicated Resident #10 when he complained of pain. She said Resident #10 could not rate his pain and would not ask for pain medication. During an interview on 7/7/16 at 2:40 p.m., LVN F said she did not medicate Resident #10 today for pain and did not medicate him this morning before following the order to flush his penis. She said she did his treatment at 9:00 a.m. that morning and did not medicate him prior to treatment. During an interview on 7/7/16 at 1:45 p.m., the DON said residents were assessed for pain every shift and she expected a resident to be medicated 30 minutes prior to a painful procedure. The DON said Resident #10 could not rate his pain on a number scale. She said she expected staff to stop a procedure if it caused pain, medicate for pain, and wait 30 minutes before proceeding. She said she expected Resident #10 to be medicated if he said he hurt. A pain management policy and procedure with a revised date of 3/2012 indicated .residents experiencing pain will be assessed and pain management provided to the degree possible to provide comfort and enhance the residents quality of life .nursing staff will identify situations or interventions where an increase in the resident's pain may be anticipated (i.e. wound care, ambulation, repositioning). Pain medication will be offered appropriately preceding these identified activities .A care plan will be completed with goals for pain treatment, pharmacological and non-pharmacological interventions. Plan will be updated appropriately . During an interview on 7/7/16 at 2:53 p.m., the DON said 40 residents received scheduled and PRN pain medication.

Based on interview and record review, the facility failed to implement policies and procedures to prohibit neglect for 1 of 4 residents reviewed for neglect. (Resident #3) Resident #3, who received daily [MEDICATION NAME] (blood thinner), reported a bloody stool at 6:00 p.m. on 5/16/15. When the bleeding continued,.the physician was notified and said to monitor. He was transferred to the local hospital 4.5 hrs. later, where he was found to have an abnormally high PT/ INR. He received a blood transfusion at the local hospital. The facility did not promptly recognize and monitor for signs and symptoms associated with adverse reactions of [MEDICATION NAME] therapy. This failure contributed to Resident #3's delay in medical treatment and could place 6 residents who received [MEDICATION NAME] at risk for bleeding. Findings included: Consolidated physician orders [REDACTED].#3 was a [AGE] year old male, admitted on [DATE] with [DIAGNOSES REDACTED]. Physician orders [REDACTED]. The most recent MDS dated [DATE] indicated Resident #3 usually was able to understand others and usually made himself understood. The MAR for April and May 2015 indicated Resident #3 was administered [MEDICATION NAME] 7 mg at 4:00 p.m. daily. A laboratory report dated 3/18/15 indicated PT was 26.2 (normal 11.0-13.5) and INR was 3.87 (0.86-1.32). The lab was noted on 3/20/15 (2 days later) with new orders to change [MEDICATION NAME] to 7 mg every day. A laboratory report dated 4/17/15 indicated PT was 22.7 and INR 3 with no changes made. A care plan for Resident #3 dated 2/12/15 did not indicate anticoagulant use. An anticoagulant flow sheet for April and May 2015 indicated the staff were to use caution when starting, changing, or discontinuing any medications on residents taking [MEDICATION NAME]. A recheck of PT/INR may be warranted within 7-14 days of a medication change. Staff should monitor for signs and symptoms of bleeding and notify the physician of any changes in condition. The flow sheets indicated Resident #3 had no bleeding, including on 5/16/15 or on the 10 p.m. - 6 a.m. shift. Nursing notes dated 12/14/15 to 5/15/15 indicated there was no indication Resident #3 had hemorrhoids or previous complaints of blood in his stool. Nursing notes dated 5/16/15 and 5/17/15 for Resident # 3 indicated: *On 5/16/15 at 6:00 p.m., Resident #3 reported bleeding with stool due to hemorrhoids twice. Examination of a stool sample indicated there was a small amount of blood noted with the stool. The resident refused to let the nurse examine for hemorrhoids. He denied any pain or discomfort. The resident was informed to pull the call light if any other stools passed with blood. His vital signs were within normal limits but no vital signs were listed. At 9:00 p.m., Resident #3 was noted as resting in the bed with no other complaints of bleeding. The note indicated the next shift would continue to monitor and all vital signs were within normal limits but no vital signs were listed. The note indicated the resident denied any pain and this would be noted on a 24 hour report. *On 5/17/15 at 2:30 a.m., Resident #3 reported bleeding hemorrhoids, 200 cubic centimeters (cc) of blood noted in the urine specimen container. The resident denied any pain or discomfort. The on call physician was notified with new orders obtained to hold [MEDICATION NAME] for 2 days, if the bleeding stopped, resume [MEDICATION NAME], and if bleeding continued to send the resident to the emergency room . The notes indicated the resident was notified, MAR and 24 hour report updated, and staff would continue to monitor. *On 5/17/15 at 6:40 a.m., Resident #3 reported rectal bleeding every hour during the night. The resident was sent to the emergency room for rectal bleeding and vomiting. At 6:55 a.m., EMS at facility to transport to emergency room . Vital signs stable, resident awake and alert and denied discomfort. Resident reported he would call his family from his cell phone. Hospital emergency room records dated 5/17/15 at 7:13 a.m., indicated Resident #3 had a lower GI bleed in serious condition. The record indicated his blood pressure was 60/30, pulse was 117, respiration was 28, PT was 27.3 and INR 4.06. The resident was administered blood and transferred to another hospital for a higher level of care. Hospital records from the other hospital dated 5/17/15 indicated Resident #3 was admitted at 11:08 a.m. with [DIAGNOSES REDACTED]. He had active rectal bleeding. A laboratory report indicated his PT was 45.5 and INR was 4.4. He was administered Vitamin K (used to make the blood to clot). During an interview on 5/19/15 at 3:10 p.m., CNA F said she worked the 2-10 shift on 5/16/15. She said Resident #3 was independent with care. She said she was not aware he had rectal bleeding or she would have checked on him before the end of her shift. She said he never complained of hemorrhoids or rectal bleeding to her. During an interview on 5/19/15 at 10:05 a.m., CNA E said Resident #3 had not reported having hemorrhoids or rectal bleeding to her. She said he was independent with activities of daily living. During an interview on 5/19/15 at 10:49 a.m., LVN A said Resident #3 had no history of hemorrhoids or rectal bleeding. She said he had no medication ordered for hemorrhoids. LVN A said when a resident was on [MEDICATION NAME] and blood was observed with the stool that would be considered a change in condition and the physician should be notified. During an interview on 5/19/15 at 12:00 p.m., the DON said she was not aware of Resident #3 going to the hospital until 5/18/15 when she arrived to work. She said she planned on having an in-service with the staff about monitoring for potential adverse reactions/side effects of anticoagulants, notifying physicians, DON and responsible party with resident changes in condition. The DON said if LVN B had notified her of Resident #3 having rectal bleeding, which was a change, and he would not allow her to assess for hemorrhoids she could had directed her on the next step to take which would have been to notify the physician of a change in condition. During a telephone interview on 5/19/15 at 12:20 p.m., LVN B said she worked at the facility for about 9 months and that was the first time Resident #3 complained of rectal bleeding/hemorrhoids to her. LVN B said Resident #3 reported to her at 6:00 p.m. on 5/16/15 his hemorrhoids were acting up and bleeding. She said he reported he had a bowel movement with some blood in it but he already flushed it. LVN B said she put a container in the commode to catch the next stool so she could look at it. She said Resident #3 had another bowel movement and there was a small amount of blood noted in the stool. She said she attempted to assess for hemorrhoids, but he refused. She said she told him if he had anymore bleeding to let her know. She said she checked on him around 8 or 9 p.m. and he said he was "ok". She said she did not consider possible side effect/adverse reaction from the [MEDICATION NAME] because he said the bleeding was from hemorrhoids. She said she took his vital signs and remembered they were within normal limits. She said she told LVN C of Resident #3's complaints of blood in his stool so she could follow up on the 10 p.m. - 6 a.m. shift. LVN B said Resident #3 was always at the nurses station to have his blood sugar checked when she arrived to work at 5:45 -6:00 a.m., because he wanted to be first. She said she went to Resident #3's room to check on him at approximately 6:40 a.m. and he was seated in his wheelchair in his boxers. She said he reported he had bled all night, every hour and sometimes more than that. She said he asked her to help clean him up and she noticed he did not have hemorrhoids but bleeding from his rectum. She said he had "quite a bit" of blood in the seat of his wheelchair. She said she checked his blood sugar because she knew he was going to the hospital. She said she took his vital signs but forgot to write them down, they were within normal limits. She said she did not do a transfer sheet for the emergency services because she could not find one, but gave them a copy of his MARS. LVN B said LVN C notified the physician during her shift, received new orders and documented in her report he was "fine". LVN B said he threw up when she was making copies of his MARs, but it was clear, no blood or coffee grounds substance was observed. During a telephone interview on 5/19/15 at 12:35 p.m., Resident #3 said he reported and showed LVN B he was passing blood when he had a bowel movement. She told him he probably had hemorrhoids. He said he told LVN B he was still bleeding at 8:00 p.m. but she did not call the physician. He said he told LVN C several times on the 10 p.m. - 6 a.m. shift he was bleeding. He said she finally notified the physician about 2:00 a.m. and told him they were to hold his [MEDICATION NAME] for two days. He said he did not see anyone again until LVN B came to his room to check on him around 6:30 a.m. He said he was so weak and sick he could not get himself dressed. He said he had nausea and vomiting that morning after the LVN checked on him around 6 a.m. He said the vomit was like "coffee grounds." During a telephone interview on 5/19/15 at 1:40 p.m., LVN C said LVB B told her during shift change Resident #3 was having rectal bleeding, but did not know how much. LVN C said Resident #3 reported to her he still had some bleeding. She said she observed approximately 200 cc of blood in the container in the commode. She said she did not know if that just happened or if it was over time since he first reported the blood. She said she notified the on call physician and orders were given to hold the [MEDICATION NAME] for 2 days then if the bleeding stopped to resume the [MEDICATION NAME], if he continued to have bleeding to send to the emergency room . LVN C said she checked on Resident #3 again at 5:00 a.m. and he said he was "fine". She said she did not turn back the covers to see if he had any blood on clothing/linen or look in the container in the bathroom to see if there was any more blood. She said she took his vital signs and they were within normal range but forgot to document them. During an interview on 5/19/15 at 3:00 p.m., LVN D said Resident #3 never complained of rectal bleeding or hemorrhoids to her. She said that would be a change of condition for Resident #3 especially since he was on [MEDICATION NAME] and the physician should had been notified when first reported. The Abuse-Reportable Events policy dated 5/2014 indicated neglect was the failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. The Lab Monitoring policy - Therapeutic Levels policy dated 03/2012 indicated to note any medications the resident is taking that could affect the lab value. Abnormal labs were to be faxed to the physician and if no response within 24 hours to call and notify them of the lab results. The Change of Condition - Observing, Reporting and Recording policy dated 3/2012 indicated the facility was to notify the physician and responsible party when there was a change in condition. A thorough comprehensive assessment was to be performed and documented. A list obtained from the DON on 5/20/15 indicated 6 residents received [MEDICATION NAME].

Based on interview and record review the facility failed to ensure monitoring of medications for 1 of 3 residents reviewed for [MEDICATION NAME] Therapy. (Resident #3) Resident #3, who received daily [MEDICATION NAME] (blood thinner), reported a bloody stool at 6:00 p.m. on 5/16/15. When the bleeding continued,.the physician was notified and said to monitor. He was transferred to the local hospital 4.5 hrs. later, where he was found to have an abnormally high PT/ INR. He received a blood transfusion at the local hospital. The facility did not promptly recognize and monitor for signs and symptoms associated with adverse reactions of [MEDICATION NAME] therapy. This failure contributed to Resident #3's delay in medical treatment and could place 6 residents who received [MEDICATION NAME] at risk for bleeding. Findings included: Consolidated physician orders [REDACTED].#3 was a [AGE] year old male, admitted on [DATE] with [DIAGNOSES REDACTED]. Physician orders [REDACTED]. The most recent MDS dated [DATE] indicated Resident #3 usually was able to understand others and usually made himself understood. The MAR for April and May 2015 indicated Resident #3 was administered [MEDICATION NAME] 7 mg at 4:00 p.m. daily. A laboratory report dated 3/18/15 indicated PT was 26.2 (normal 11.0-13.5) and INR was 3.87 (0.86-1.32). The lab was noted on 3/20/15 (2 days later) with new orders to change [MEDICATION NAME] to 7 mg every day. A laboratory report dated 4/17/15 indicated PT was 22.7 and INR 3 with no changes made. A care plan for Resident #3 dated 2/12/15 did not indicate anticoagulant use. An anticoagulant flow sheet for April and May 2015 indicated the staff were to use caution when starting, changing, or discontinuing any medications on residents taking [MEDICATION NAME]. A recheck of PT/INR may be warranted within 7-14 days of a medication change. Staff should monitor for signs and symptoms of bleeding and notify the physician of any changes in condition. The flow sheets indicated Resident #3 had no bleeding, including on 5/16/15 or on the 10 p.m. - 6 a.m. shift. Nursing notes dated 12/14/15 to 5/15/15 indicated there was no indication Resident #3 had hemorrhoids or previous complaints of blood in his stool. Nursing notes dated 5/16/15 and 5/17/15 for Resident # 3 indicated: *On 5/16/15 at 6:00 p.m., Resident #3 reported bleeding with stool due to hemorrhoids twice. Examination of a stool sample indicated there was a small amount of blood noted with the stool. The resident refused to let the nurse examine for hemorrhoids. He denied any pain or discomfort. The resident was informed to pull the call light if any other stools passed with blood. His vital signs were within normal limits but no vital signs were listed. At 9:00 p.m., Resident #3 was noted as resting in the bed with no other complaints of bleeding. The note indicated the next shift would continue to monitor and all vital signs were within normal limits but no vital signs were listed. The note indicated the resident denied any pain and this would be noted on a 24 hour report. *On 5/17/15 at 2:30 a.m., Resident #3 reported bleeding hemorrhoids, 200 cubic centimeters (cc) of blood noted in the urine specimen container. The resident denied any pain or discomfort. The on call physician was notified with new orders obtained to hold [MEDICATION NAME] for 2 days, if the bleeding stopped, resume [MEDICATION NAME], and if bleeding continued to send the resident to the emergency room . The notes indicated the resident was notified, MAR and 24 hour report updated, and staff would continue to monitor. *On 5/17/15 at 6:40 a.m., Resident #3 reported rectal bleeding every hour during the night. The resident was sent to the emergency room for rectal bleeding and vomiting. At 6:55 a.m., EMS at facility to transport to emergency room . Vital signs stable, resident awake and alert and denied discomfort. Resident reported he would call his family from his cell phone. Hospital emergency room records dated 5/17/15 at 7:13 a.m., indicated Resident #3 had a lower GI bleed in serious condition. The record indicated his blood pressure was 60/30, pulse was 117, respiration was 28, PT was 27.3 and INR 4.06. The resident was administered blood and transferred to another hospital for a higher level of care. Hospital records from the other hospital dated 5/17/15 indicated Resident #3 was admitted at 11:08 a.m. with [DIAGNOSES REDACTED]. He had active rectal bleeding. A laboratory report indicated his PT was 45.5 and INR was 4.4. He was administered Vitamin K (used to make the blood to clot). During an interview on 5/19/15 at 3:10 p.m., CNA F said she worked the 2-10 shift on 5/16/15. She said Resident #3 was independent with care. She said she was not aware he had rectal bleeding or she would have checked on him before the end of her shift. She said he never complained of hemorrhoids or rectal bleeding to her. During an interview on 5/19/15 at 10:05 a.m., CNA E said Resident #3 had not reported having hemorrhoids or rectal bleeding to her. She said he was independent with activities of daily living. During an interview on 5/19/15 at 10:49 a.m., LVN A said Resident #3 had no history of hemorrhoids or rectal bleeding. She said he had no medication ordered for hemorrhoids. LVN A said when a resident was on [MEDICATION NAME] and blood was observed with the stool that would be considered a change in condition and the physician should be notified. During an interview on 5/19/15 at 12:00 p.m., the DON said she was not aware of Resident #3 going to the hospital until 5/18/15 when she arrived to work. She said she planned on having an in-service with the staff about monitoring for potential adverse reactions/side effects of anticoagulants, notifying physicians, DON and responsible party with resident changes in condition. The DON said if LVN B had notified her of Resident #3 having rectal bleeding, which was a change, and he would not allow her to assess for hemorrhoids she could had directed her on the next step to take which would have been to notify the physician of a change in condition. During a telephone interview on 5/19/15 at 12:20 p.m., LVN B said she worked at the facility for about 9 months and that was the first time Resident #3 complained of rectal bleeding/hemorrhoids to her. LVN B said Resident #3 reported to her at 6:00 p.m. on 5/16/15 his hemorrhoids were acting up and bleeding. She said he reported he had a bowel movement with some blood in it but he already flushed it. LVN B said she put a container in the commode to catch the next stool so she could look at it. She said Resident #3 had another bowel movement and there was a small amount of blood noted in the stool. She said she attempted to assess for hemorrhoids, but he refused. She said she told him if he had anymore bleeding to let her know. She said she checked on him around 8 or 9 p.m. and he said he was "ok". She said she did not consider possible side effect/adverse reaction from the [MEDICATION NAME] because he said the bleeding was from hemorrhoids. She said she took his vital signs and remembered they were within normal limits. She said she told LVN C of Resident #3's complaints of blood in his stool so she could follow up on the 10 p.m. - 6 a.m. shift. LVN B said Resident #3 was always at the nurses station to have his blood sugar checked when she arrived to work at 5:45 -6:00 a.m., because he wanted to be first. She said she went to Resident #3's room to check on him at approximately 6:40 a.m. and he was seated in his wheelchair in his boxers. She said he reported he had bled all night, every hour and sometimes more than that. She said he asked her to help clean him up and she noticed he did not have hemorrhoids but bleeding from his rectum. She said he had "quite a bit" of blood in the seat of his wheelchair. She said she checked his blood sugar because she knew he was going to the hospital. She said she took his vital signs but forgot to write them down, they were within normal limits. She said she did not do a transfer sheet for the emergency services because she could not find one, but gave them a copy of his MARS. LVN B said LVN C notified the physician during her shift, received new orders and documented in her report he was "fine". LVN B said he threw up when she was making copies of his MARs, but it was clear, no blood or coffee grounds substance was observed. During a telephone interview on 5/19/15 at 12:35 p.m., Resident #3 said he reported and showed LVN B he was passing blood when he had a bowel movement. She told him he probably had hemorrhoids. He said he told LVN B he was still bleeding at 8:00 p.m. but she did not call the physician. He said he told LVN C several times on the 10 p.m. - 6 a.m. shift he was bleeding. He said she finally notified the physician about 2:00 a.m. and told him they were to hold his [MEDICATION NAME] for two days. He said he did not see anyone again until LVN B came to his room to check on him around 6:30 a.m. He said he was so weak and sick he could not get himself dressed. He said he had nausea and vomiting that morning after the LVN checked on him around 6 a.m. He said the vomit was like "coffee grounds". During a telephone interview on 5/19/15 at 1:40 p.m., LVN C said LVB B told her during shift change Resident #3 was having rectal bleeding, but did not know how much. LVN C said Resident #3 reported to her he still had some bleeding. She said she observed approximately 200 cc of blood in the container in the commode. She said she did not know if that just happened or if it was over time since he first reported the blood. She said she notified the on call physician and orders were given to hold the [MEDICATION NAME] for 2 days then if the bleeding stopped to resume the [MEDICATION NAME], if he continued to have bleeding to send to the emergency room . LVN C said she checked on Resident #3 again at 5:00 a.m. and he said he was "fine". She said she did not turn back the covers to see if he had any blood on clothing/linen or look in the container in the bathroom to see if there was any more blood. She said she took his vital signs and they were within normal range but forgot to document them. During an interview on 5/19/15 at 3:00 p.m., LVN D said Resident #3 never complained of rectal bleeding or hemorrhoids to her. She said that would be a change of condition for Resident #3 especially since he was on [MEDICATION NAME]. The Abuse-Reportable Events policy dated 5/2014 indicated neglect was the failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. The Lab Monitoring policy - Therapeutic Levels policy dated 03/2012 indicated to note any medications the resident is taking that could affect the lab value. Abnormal labs were to be faxed to the physician and if no response within 24 hours to call and notify them of the lab results. The Change of Condition - Observing, Reporting and Recording policy dated 3/2012 indicated the facility was to notify the physician and responsible party when there was a change in condition. A thorough comprehensive assessment was to be performed and documented. A list obtained from the DON on 5/20/15 indicated 6 residents received [MEDICATION NAME].

Based on interview and record review, the facility failed to implement their written policies and procedures to prohibit neglect for 1 of 4 residents reviewed for neglect. (Resident #3) Resident #3, who received daily [MEDICATION NAME] (blood thinner), reported a bloody stool at 6:00 p.m. on 5/16/15. When the bleeding continued,.the physician was notified and said to monitor. He was transferred to the local hospital 4.5 hrs. later, where he was found to have an abnormally high PT/ INR. He received a blood transfusion at the local hospital. The facility did not promptly recognize and monitor for signs and symptoms associated with adverse reactions of [MEDICATION NAME] therapy. This failure contributed to Resident #3's delay in medical treatment and could place 6 residents who received [MEDICATION NAME] at risk for bleeding. Findings included: The Abuse-Reportable Events policy dated 5/2014 indicated neglect was the failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. The Lab Monitoring policy - Therapeutic Levels policy dated 03/2012 indicated to note any medications the resident is taking that could affect the lab value. Abnormal labs were to be faxed to the physician and if no response within 24 hours to call and notify them of the lab results. The Change of Condition - Observing, Reporting and Recording policy dated 3/2012 indicated the facility was to notify the physician and responsible party when there was a change in condition. A thorough comprehensive assessment was to be performed and documented. Consolidated physician orders [REDACTED].#3 was a [AGE] year old male, admitted on [DATE] with [DIAGNOSES REDACTED]. Physician orders [REDACTED]. The most recent MDS dated [DATE] indicated Resident #3 usually was able to understand others and usually made himself understood. The MAR for April and May 2015 indicated Resident #3 was administered [MEDICATION NAME] 7 mg at 4:00 p.m. daily. A laboratory report dated 3/18/15 indicated PT was 26.2 (normal 11.0-13.5) and INR was 3.87 (0.86-1.32). The lab was noted on 3/20/15 (2 days later) with new orders to change [MEDICATION NAME] to 7 mg every day. A laboratory report dated 4/17/15 indicated PT was 22.7 and INR 3 with no changes made. A care plan for Resident #3 dated 2/12/15 did not indicate anticoagulant use. An anticoagulant flow sheet for April and May 2015 indicated the staff were to use caution when starting, changing, or discontinuing any medications on residents taking [MEDICATION NAME]. A recheck of PT/INR may be warranted within 7-14 days of a medication change. Staff should monitor for signs and symptoms of bleeding and notify the physician of any changes in condition. The flow sheets indicated Resident #3 had no bleeding, including on 5/16/15 or on the 10 p.m. - 6 a.m. shift. Nursing notes dated 12/14/15 to 5/15/15 indicated there was no indication Resident #3 had hemorrhoids or previous complaints of blood in his stool. Nursing notes dated 5/16/15 and 5/17/15 for Resident # 3 indicated: *On 5/16/15 at 6:00 p.m., Resident #3 reported bleeding with stool due to hemorrhoids twice. Examination of a stool sample indicated there was a small amount of blood noted with the stool. The resident refused to let the nurse examine for hemorrhoids. He denied any pain or discomfort. The resident was informed to pull the call light if any other stools passed with blood. His vital signs were within normal limits but no vital signs were listed. At 9:00 p.m., Resident #3 was noted as resting in the bed with no other complaints of bleeding. The note indicated the next shift would continue to monitor and all vital signs were within normal limits but no vital signs were listed. The note indicated the resident denied any pain and this would be noted on a 24 hour report. *On 5/17/15 at 2:30 a.m., Resident #3 reported bleeding hemorrhoids, 200 cubic centimeters (cc) of blood noted in the urine specimen container. The resident denied any pain or discomfort. The on call physician was notified with new orders obtained to hold [MEDICATION NAME] for 2 days, if the bleeding stopped, resume [MEDICATION NAME], and if bleeding continued to send the resident to the emergency room . The notes indicated the resident was notified, MAR and 24 hour report updated, and staff would continue to monitor. *On 5/17/15 at 6:40 a.m., Resident #3 reported rectal bleeding every hour during the night. The resident was sent to the emergency room for rectal bleeding and vomiting. At 6:55 a.m., EMS at facility to transport to emergency room . Vital signs stable, resident awake and alert and denied discomfort. Resident reported he would call his family from his cell phone. Hospital emergency room records dated 5/17/15 at 7:13 a.m., indicated Resident #3 had a lower GI bleed in serious condition. The record indicated his blood pressure was 60/30, pulse was 117, respiration was 28, PT was 27.3 and INR 4.06. The resident was administered blood and transferred to another hospital for a higher level of care. Hospital records from the other hospital dated 5/17/15 indicated Resident #3 was admitted at 11:08 a.m. with [DIAGNOSES REDACTED]. He had active rectal bleeding. A laboratory report indicated his PT was 45.5 and INR was 4.4. He was administered Vitamin K (used to make the blood to clot). During an interview on 5/19/15 at 3:10 p.m., CNA F said she worked the 2-10 shift on 5/16/15. She said Resident #3 was independent with care. She said she was not aware he had rectal bleeding or she would have checked on him before the end of her shift. She said he never complained of hemorrhoids or rectal bleeding to her. During an interview on 5/19/15 at 10:05 a.m., CNA E said Resident #3 had not reported having hemorrhoids or rectal bleeding to her. She said he was independent with activities of daily living. During an interview on 5/19/15 at 10:49 a.m., LVN A said Resident #3 had no history of hemorrhoids or rectal bleeding. She said he had no medication ordered for hemorrhoids. LVN A said when a resident was on [MEDICATION NAME] and blood was observed with the stool that would be considered a change in condition and the physician should be notified. During an interview on 5/19/15 at 12:00 p.m., the DON said she was not aware of Resident #3 going to the hospital until 5/18/15 when she arrived to work. She said she planned on having an in-service with the staff about monitoring for potential adverse reactions/side effects of anticoagulants, notifying physicians, DON and responsible party with resident changes in condition. The DON said if LVN B had notified her of Resident #3 having rectal bleeding, which was a change, and he would not allow her to assess for hemorrhoids she could had directed her on the next step to take which would have been to notify the physician of a change in condition. During a telephone interview on 5/19/15 at 12:20 p.m., LVN B said she worked at the facility for about 9 months and that was the first time Resident #3 complained of rectal bleeding/hemorrhoids to her. LVN B said Resident #3 reported to her at 6:00 p.m. on 5/16/15 his hemorrhoids were acting up and bleeding. She said he reported he had a bowel movement with some blood in it but he already flushed it. LVN B said she put a container in the commode to catch the next stool so she could look at it. She said Resident #3 had another bowel movement and there was a small amount of blood noted in the stool. She said she attempted to assess for hemorrhoids, but he refused. She said she told him if he had anymore bleeding to let her know. She said she checked on him around 8 or 9 p.m. and he said he was "ok". She said she did not consider possible side effect/adverse reaction from the [MEDICATION NAME] because he said the bleeding was from hemorrhoids. She said she took his vital signs and remembered they were within normal limits. She said she told LVN C of Resident #3's complaints of blood in his stool so she could follow up on the 10 p.m. - 6 a.m. shift. LVN B said Resident #3 was always at the nurses station to have his blood sugar checked when she arrived to work at 5:45 -6:00 a.m., because he wanted to be first. She said she went to Resident #3's room to check on him at approximately 6:40 a.m. and he was seated in his wheelchair in his boxers. She said he reported he had bled all night, every hour and sometimes more than that. She said he asked her to help clean him up and she noticed he did not have hemorrhoids but bleeding from his rectum. She said he had "quite a bit" of blood in the seat of his wheelchair. She said she checked his blood sugar because she knew he was going to the hospital. She said she took his vital signs but forgot to write them down, they were within normal limits. She said she did not do a transfer sheet for the emergency services because she could not find one, but gave them a copy of his MARS. LVN B said LVN C notified the physician during her shift, received new orders and documented in her report he was "fine". LVN B said he threw up when she was making copies of his MARs, but it was clear, no blood or coffee grounds substance was observed. During a telephone interview on 5/19/15 at 12:35 p.m., Resident #3 said he reported and showed LVN B he was passing blood when he had a bowel movement. She told him he probably had hemorrhoids. He said he told LVN B he was still bleeding at 8:00 p.m. but she did not call the physician. He said he told LVN C several times on the 10 p.m. - 6 a.m. shift he was bleeding. He said she finally notified the physician about 2:00 a.m. and told him they were to hold his [MEDICATION NAME] for two days. He said he did not see anyone again until LVN B came to his room to check on him around 6:30 a.m. He said he was so weak and sick he could not get himself dressed. He said he had nausea and vomiting that morning after the LVN checked on him around 6 a.m. He said the vomit was like "coffee grounds". During a telephone interview on 5/19/15 at 1:40 p.m., LVN C said LVB B told her during shift change Resident #3 was having rectal bleeding, but did not know how much. LVN C said Resident #3 reported to her he still had some bleeding. She said she observed approximately 200 cc of blood in the container in the commode. She said she did not know if that just happened or if it was over time since he first reported the blood. She said she notified the on call physician and orders were given to hold the [MEDICATION NAME] for 2 days then if the bleeding stopped to resume the [MEDICATION NAME], if he continued to have bleeding to send to the emergency room . LVN C said she checked on Resident #3 again at 5:00 a.m. and he said he was "fine". She said she did not turn back the covers to see if he had any blood on clothing/linen or look in the container in the bathroom to see if there was any more blood. She said she took his vital signs and they were within normal range but forgot to document them. During an interview on 5/19/15 at 3:00 p.m., LVN D said Resident #3 never complained of rectal bleeding or hemorrhoids to her. She said that would be a change of condition for Resident #3 especially since he was on [MEDICATION NAME] and the physician should had been notified when first reported. A list obtained from the DON on 5/20/15 indicated 6 residents received [MEDICATION NAME].

Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 5 residents reviewed for falls. (Resident #52) Resident #52 sustained 5 falls over a 4 week time period. On 09/06/14, Resident #52 had a fall resulting in a head injury. The facility did not implement new interventions to prevent injuries from falls for Resident #52. Two days later, Resident #52 fell again and was hospitalized . This failure could place 15 residents who required ambulation assistance at risk for falls and injuries. Findings included: Physician orders [REDACTED].#52 was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. The orders indicated he was on no psychotropic medications. A telephone order for Resident #52 dated 06/10/14 indicated, "May use Merry Walker (an assistive device for walking)." The most recent MDS dated [DATE] indicated Resident #52 had severely impaired cognition, was totally incontinent, and required extensive assistance for transfers, ambulation, and all activities of daily living. The Merry Walker was coded as a restraint. A fall care plan for Resident #52 initiated 02/27/14 and updated 05/09/14 indicated the following: "Resident has a history of falls and is at risk for increased falls and/or fractures. Goal: dignity of resident will be maintained. Incidence of falls will be reduced and no occurrence of injury will occur over the next 90 days. Approach: 1. Encourage resident to ask for assistance of staff. 2. Ensure call light is within reach, answer promptly. 3. Therapy to evaluate and treat per orders. 4. Anticipate resident's needs, provide prompt assistance. 5. Assure lighting is adequate and areas are free of clutter. 6. Encourage socialization and activity attendance as tolerated." The care plan was reviewed 06/05/14 and the status was to continue the plan of care. A care plan for Resident #52 initiated 07/08/14 indicated the following: "Resident requires the use of a restraint." Merry Walker and "To prevent resident from trying to get up without assistance" were marked on the care plan. During an observation and interview on 09/08/14 at 9:04 a.m., Resident #52 was in his room standing in his Merry Walker with his pants around his ankles. He was confused and could not say what he needed. His bed had a scoop mattress, was in the low position, and he had a fall mat. A form provided by PT L on 09/09/14 at 1:15 p.m. indicated Resident #52 was on PT and OT from 07/21/14 through 09/03/14. An incident report dated 08/04/14 at 9:10 p.m. indicated Resident #52 was found on the floor on his hands and knees in front of his Merry Walker. He had no injuries. The report indicated dementia was the cause of the occurrence. Under "What measures were put in place or what systemic changes were made?", "Cont. (continue) PT (physical therapy) and OT (occupational therapy)" was documented. There was no documentation of new interventions. There was no fall risk assessment with the incident report. An incident report dated 08/08/14 at 8:00 a.m. indicated Resident #52 was found on the floor with his pants around his ankles. He had no injuries. The report indicated the resident tried to get dressed without assistance and fell , but the fall was unwitnessed. Under "What measures were put in place or what systemic changes were made?", "Non-skid socks put on feet, currently in PT, bed in lowest position and fall mats in place" were documented. A care plan for Resident #52 dated 08/08/14 indicated "Resident had an episode of fall." The new intervention was "Non-skid socks put on feet." An incident report dated 08/23/14 at 10:00 p.m. indicated Resident #52 was found lying on the floor in his room on his left side. He had no injuries. The report indicated unsteady balance was cause of the occurrence. Under "What measures were put in place or what systemic changes were made?", "frequent room checks, PT referral (he was already on PT), and scoop mattress" were documented. A care plan for Resident #52 dated 08/25/14 indicated "Resident had an episode of a fall." The new intervention was "scoop mattress." An incident report dated 09/06/14 at 7:15 p.m. indicated Resident #52 was found lying on the floor on his left side with his Merry Walker on his left arm. The report indicated the resident had unsteady gait and fell . Under "What measures were put in place or what systemic changes were made?", "toileting schedule" was documented. The report indicated the resident was sent to the emergency room . Nursing notes dated 09/06/14 at 7:15 p.m. indicated Resident #52 had "some bleeding coming from the (L) (left) side of his head." The nursing notes indicated he returned to the facility at 11:00 p.m. with a dressing to his left elbow and a laceration to his left eyebrow that was closed with surgical glue. There were no other fall care plans for Resident #52 added following this fall or any other updates to his current fall or fall risk care plans. During an interview on 09/09/14 at 1:30 p.m., the LVN Medicaid MDS/Care Plan coordinator brought another copy of the care plan for Resident # 52 dated 08/25/14. An intervention dated 09/06/14 had been added: "toileting schedule." She said Resident #52 had severely impaired cognition and was incontinent of bowel and bladder per his last MDS dated [DATE]. She indicated the resident would be unable to participate in a toileting schedule. An incident report dated 09/08/14 at 10:40 a.m. indicated Resident #52 fell in the hallway with his Merry Walker was on top of him. His face and head were on the floor and his arm was under him. He was sent to the emergency room for evaluation. There was no fall risk assessment with the incident report. During an interview on 09/08/14 at 3:42 p.m., the ADON said Resident #52 was admitted to the hospital for further evaluation of his falls. During an interview on 09/09/14 at 11:30 a.m., the LVN Medicaid MDS/Care Plan coordinator said the DON or ADON usually initiated actual fall care plans following falls. She said there were no other actual fall or fall prevention care plans for Resident #52. During an interview on 09/09/14 at 3:25 p.m., the ADON said fall risk assessments should be done after each fall. She indicated the nurse who filled out the incident report following a fall should also do a fall risk assessment. During an interview on 09/09/14 at 3:40 p.m., the interim DON and ADON said new interventions should have been tried following each of Resident #52's falls. The ADON said putting the bed in the lowest position and a fall mat were both initiated prior to implementation of the Merry Walker on 06/10/14, but was unsure of the exact day(s) they were implemented. The ADON indicated they had considered the Merry Walker Resident #52 currently used might be contributing to his falls. The ADON said they considered ordering a PVC-type Merry Walker which might have more stability. All staff fall prevention in-services were dated 03/14/14 and 06/30/14, but they did not specify what information was covered in those in-services. A Falls Evaluation and Prevention policy and procedure revised 03/2012 indicated the following: "Residents should be evaluated for their fall risk...following a fall... Extrinsic factors for falls are part of the resident's environment and are most likely to be seen in areas such as the bedroom, bathroom, dining room, and hallways. The following are typical examples of extrinsic risk factors: Mechanical restraints... Following a fall, the following steps should be undertaken...evaluate the environment where the fall occurred, noting any factors that may have contributed to the fall...Review the plan of care and update the interventions as appropriate." The CMS 672 dated 09/08/14 indicated 15 residents required assistance with ambulation or assistive devices.

Based on observation, interview, and record review, the facility failed to provide care and services in accordance with the comprehensive assessment and plan of care to ensure adequate pain relief for 1 of 9 residents reviewed for pain (Resident #3) and wound assessment for 1 of 10 residents reviewed for assessment. (Resident #7) 1. Interventions for pain were not provided for Resident #3. During incontinent care and wound care, Resident #3 experienced severe buttock pain. The treatment nurse did not discontinue the treatment when the resident complained of pain. 2. Resident #7s skin tears were not assessed. This failure contributed to Resident # 3's unrelieved pain and could place 46 residents receiving pain management at risk for unrelieved pain and 20 residents with wounds at risk of decline in existing wounds. Findings included: 1. Physicians orders dated July 2013 indicated Resident #3, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. The order noted Resident #3 was to receive [MEDICATION NAME] 5/325mg 1-2 tabs every six hours as needed for pain, [MEDICATION NAME] 50 mg 1-2 tabs every six hours as needed for pain, and [MEDICATION NAME] 325 mg 2 tablets every 6 hours as needed for pain. Nursing staff were to conduct a pain assessment and record results every shift. The most recent MDS dated [DATE] indicated Resident #3 was able to understand others and make himself understood. Resident #3 required extensive assistance of two people for bed mobility, dressing, personal hygiene, and was totally dependent on two people for transfers. The assessment did not indicate the resident had pain. A comprehensive pain assessment dated [DATE] indicated Resident #3 had generalized pain of 4 on a scale of 1-10 (very slight to severe pain). An acute plan of care dated 07/15/13 indicated Resident #3 had a shearing wound to his coccyx and upper buttocks, the approach was to provide treatment and to monitor for signs and symptoms of infection, drainage, foul odor, redness, pain, and report to the physician. During an observation on 07/15/13 at 3:00 p.m. CNA N removed Resident #3's brief and cleaned his buttocks. Resident #3 moaned and tensed up when CNA N wiped him. CNA N wiped Resident #3's buttocks again and he stated, "Oh" and tensed up. CNA N apologized. The treatment nurse then sprayed wound cleanser on Resident #3's buttocks and wiped the area with 4x4 gauze. The resident tensed up and stated, "That hurts". The treatment nurse apologized and wiped the area again. Resident #3 tensed up and stated, "Oh" when she wiped the area again. The treatment nurse asked Resident #3 to rate his pain on a scale of 1-10. He rated his pain at an 8 and said stated, "It hurts when you touch it." The treatment nurse continued the treatment and sent CNA N to get LVN L to medicate Resident #3 for pain. The treatment nurse finished Resident #3's treatment. LVN L entered the room and asked Resident #3 to rate his pain. He rated the pain at a 10 on 1-10 scale. During an interview on 07/15/13 at 3:30 p.m., CNA N said Resident #3 complained of pain sometimes when they provided incontinent care. CNA N said when the area was red it probably did not hurt as much as it did now since the area was open. During an interview on 07/16/13 at 10:54 a.m., the treatment nurse said that was the first treatment she had provided to Resident #3's buttock. The treatment nurse said she should have assessed his pain scale before the treatment started. She said when Resident #3 told her the pain was an 8 on a 1-10 scale and worse when touched; she should have stopped the treatment. 2. Physician orders [REDACTED]. A care plan dated 07/11/13 indicated Resident #7 had a problem of skin tear due to a fall. The plan indicated a skin assessment would be done daily during care and a weekly skin assessment was to be done by the charge nurse. During an observation and interview on 07/14/13 at 11:36 a.m., Resident #7 had a raised area to the left side of his forehead that was yellow and blue in color. The right side of his forehead had staples. His right ear had a black scab. He had a sling on his right arm. The right elbow area was covered with a bandage. The left arm was covered with a bandage from the fingers to past the elbow area. The fingers were swollen with multiply skin tears and the arm area above the elbow area was swollen with multiple bruises. LVN K said the resident was admitted 1 week ago. LVN K said the resident had a fall prior to admission and a fall after admission that resulted in additional skin tears. A nursing note dated 07/01/13 at 5:05 p.m. indicated Resident #7 was found on his left side on the floor in his room. A head-to-toe assessment was completed. The resident had an 8.0 cm x 4.0 cm raised area to the left side of his forehead, "light purplish in color ", numerous skin tears to the left hand, and the outside of the left wrist was "swelling." A Weekly Skin Assessments for Resident #7 indicated the following: *07/08/13 area to the right big toe that was red, ear with sutures and bruise, bruise on the back, skin tear to the left back area of the arm, bruises to the right hand; and *07/11/13 two x marks were noted on the right arm and one on the back of the arm. There was no assessment information regarding the areas. During an interview on 7/14/13 at 4:34 p.m., the treatment nurse said Resident #7 had a fall after he was admitted which resulted in skin tears and multiple bruises. The treatment nurse said she did not have any skin assessment sheets regarding the new skin tears. She said she followed the skin tear protocol for assessment. The undated protocol for skin tears ordered by Resident #7's physician indicated the wounds would be assessed and monitored daily. During an observation and interview on 07/15/13 at 3:32 p.m. The treatment nurse said today (07/15/13) was the first day she changed the bandage. The resident had multiple bruising on the arm, fingers and elbow area. The areas were black and blue. The resident had an open skin tear that measured 7.0 cm by 10.0 cm. His fingers were swollen and had multiple black, scabbed areas. The right elbow had a scabbed area that was not measured. During an interview on 7/15/13 at 4:20 p.m. the DON said wounds should be assessed. The DON said assessment included measurements, drainage color and odor, and location. The Pain Management policy and procedure revised 06/13 indicated: "Each resident's pain will be assessed using the Comprehensive Pain Assessment upon admission, re-admission, the onset or an increase in pain, quarterly and whenever there is a significant change in condition that may cause an increase in pain. *Nursing staff will identify situations or interventions where an increase in the resident's pain may be anticipated (i.e. wound care, ambulation, repositioning). Pain medication will be offered appropriately preceding these identified activities. A list provided by the DON dated 07/16/13 indicated 20 residents had wounds. The CMS 672 dated 07/14/13 indicated 46 residents received pain management.

Based on interview and record review, the facility failed to provide supervision and prevent accidents for 1 of 7 residents reviewed for accidents. (Resident #1) Resident #1 was at risk for falls and fractured her hip after a fall on 11/11/12. Staff failed to place a fall mat beside the resident's bed. This failure could place 25 residents who were high risk for falls at risk for injury. Findings included: Physician orders [REDACTED]. The MDS dated [DATE] indicated Resident #1 was severely cognitively impaired, dependent on two staff for transfers, was unsteady and only able to stabilize with staff assistance. The nurse aide care plan dated 7/30/12 indicated Resident #1 indicated positioning devices in use were bed alarm, chair alarm, low bed and fall mat. The care plan dated 8/17/12 indicated Resident #1 had a potential for falls due to psychotropic medication use and unsteady balance. She required the use of a wheelchair due to immobility. Interventions listed required the assistance of 2 staff for transfers. The care plan dated 9/12/12 indicated Resident #1's problem was a fall with no injury. Interventions listed on the care plan were a low bed and a bed alarm. An incident report dated 11/11/12 indicated Resident #1 was found lying on the floor beside her bed by the 10 p.m. - 6 a.m. charge nurse at 6:00 a.m. LVN A said she heard the bed alarm and the resident hit the floor at the same time. The report indicated the bed was on a low bed and resident was lying on her right side. The resident was transferred to the hospital by EMS. An Incident/Accident Final disposition report dated 11/11/12 indicated Resident #1 had rolled off her bed onto the floor. Interviews in the report from staff working the previous 2 p.m.-10 p.m. and 10 p.m.-6 a.m. shift indicated the fall mat had not been placed beside Resident #1's bed when she was transferred to bed 11/19/12 at 10:00 p.m. During an interview on 11/19/12 at 5:40 a.m., CNA C said she did not remember seeing Resident #1's fall matt in place on the night she fell . She said that the fall matt should have been in front of the bed, it was part of the facilities fall precaution interventions. She said Resident #1 had a bed alarm, low bed and fall matt in place for prevention falls and injuries. During an interview on 11/19/12 at 6:45 a.m., LVN A said she was walking down the hall and heard Resident #1's alarm sounding and she heard her hit the floor at about the same time. She said the resident was on fall precautions because of her history of falls and high risk for falls. She said interventions to prevent injury included a bed/chair alarm, low bed and fall mat beside the bed. She said she had been in the resident's room during the night, but had not noticed the fall mat was not in place. During an interview on 11/19/12 at 8:50 a.m., CNA G said fall precautions for Resident #1 included a low bed, fall mat, and chair/bed alarm. During an interview on 11/19/12 at 9:10 a.m., LVN B said fall precautions for Resident #1 included a low bed, chair/bed alarm, and a fall mat beside her bed. During an interview on 11/19/12 at 11:00 a.m., CNA I said fall precautions for Resident #1 included a chair/bed alarm, a low bed, and a fall mat next to her bed. During an interview on 11/19/12 at 12:30 p.m., CNA D said when she put Resident #1 to bed on 11/10/12 at 10:00 p.m., she failed to put the fall mat beside her bed. She said fall precautions for the resident included a low bed, fall mat, and bed/chair alarm. During an interview on 11/19/12 at 2:00 p.m., CNA H said Resident #1 was quiet during the night and she did not think to put the fall mat in place. During an interview on 11/19/12 at 2:15 p.m., the DON said that Resident #1 was a high fall risk and had a history of [REDACTED]. The DON said the staff failed to place the fall mat at Resident #1's bedside during the 10 p.m. to 6 a.m. shift on 11/19/12. She said the resident was transferred to the emergency room for evaluation and admitted for a fractured hip. The incident/accident logs for September 2012 - November 2012 indicated Resident #1 fell on the following dates: *9/12/12 - fall out of chair at nurses' station no injury; and *11/11/12 - fall out of bed, fractured hip. Falls-Evaluation and Prevention policy dated 3/2012 indicated: *It is the policy of this home to evaluate residents for their fall risk and develop interventions for prevention. *Intervention suggestions for fall prevention: .....place bed in lowest position and lock wheels; ....position bed so that the exit is toward the resident strong side; and ...utilize bed and/or chair alarms if necessary. A list provided by the DON on 11/19/12 indicated 25 residents were high risk for falls and utilized fall mats.

Based on observation, interview, and record review, the facility failed to prevent pressure sore development and provide pressure relief, repositioning and dietary consult to promote the healing of pressure sores for 1 of 6 residents sampled for the development of pressure sores (Resident #5). Resident #5 had a history of [REDACTED]. The resident had a 10.7% weight loss from 10/4/10 - 10//26/10. The facility did not consult the dietitian regarding the resident's pressure sores and weight loss and did not provide repositioning and pressure relief. These failures contributed to the redevelopment of avoidable Stage II pressure sores for Resident #5. These failures could place 60 residents who received preventative skin care at risk for development of avoidable pressure sores and the 6 residents with pressure sores at risk for delay in healing and redevelopment of healed pressure sores. Findings included: October 2010 physician orders [REDACTED]. The orders required [MEDICATION NAME] be applied to his "coccyx area" every shift and as needed for redness. Resident #5 was to be weighed 3 times a week and the nurse practitioner was to be notified if he gained or lost 3 pounds. Resident #5's most current MDS dated [DATE] indicated he was not cognitively impaired; he was dependent on staff for ADLs, and required supervision and cueing with meals. The MDS indicated he had a Stage I pressure sore. Resident #5's skin integrity care plan dated 7/7/10 included the following interventions: * reposition every 2 hours, * provide a pressure reduction mattress, * provide adequate hydration, and * complete a nutrition assessment on admission/readmission and change of condition. Resident #5's care plan dated 9/30/10 noted he was at risk for dehydration and compromised nutrition. Resident #5's pressure sore risk assessment dated [DATE] noted he was at a high risk for developing pressure sores. On 10/26/10 at 12:20 p.m., Resident #5 was observed sitting at the dining table with oxygen via nasal canula. He had toilet paper between his ears and the oxygen tubing. Resident #5 was not eating. Several staff walked past the resident without encouraging or cueing him to eat or drink. Resident #5 ate approximately 25% of his meal and drank approximately 50% of his tea. On 10/26/10 at 2:10 p.m., Resident #5 was observed lying in bed on his back with his feet against the footboard. His heels were not offloaded. He said he had been lying on his back since about 1:15 p.m. During an observation on 10/26/10 at 3:48 p.m., Resident #5 was lying in bed on his back and his heels were not offloaded. He was receiving oxygen via nasal canula. There was no padding between the oxygen tubing and his ears. During an observation and interview on 10/26/10 at 4:00 p.m., Resident #5 was lying on his back. His feet were against the footboard. His heels were not offloaded. He said his buttocks were sore and his feet were hurting. During an observation and interview with the treatment LVN and CNA E on 10/26/10 at 4:05 p.m., the treatment LVN removed the oxygen tubing from around Resident #5's ears. The resident told the treatment LVN to be careful because his ear was sore. There was a bright, red area on the resident's left ear. The treatment LVN said it was a new Stage ll pressure sore. The resident was repositioned on his side. He had been incontinent of bowel and bladder. He had two pressure sores on his right buttock. CNA E provided incontinent care for Resident #5, but she did not clean the resident's buttocks. The treatment LVN said the resident did not have pressure sores last week, but he had a history of [REDACTED]. The treatment LVN measured the pressure sores as follows: - A new 1 cm X 0.5 cm red open area on his left ear. - A 0.3 cm X 0.2 cm Stage ll pressure sore that had redeveloped on his right medial buttock and; - A 1 cm X 0.7 cm Stage ll pressure sore that had redeveloped on his right lateral buttock. CNA E covered the uncleaned wounds with [MEDICATION NAME]. The treatment LVN said Resident #5's feet should be offloaded and should not be against the footboard. Resident #5's skin assessment sheets noted the following: - 7/7/10 - admitted with two Stage II pressure sores on his right buttock, a Stage II on his left buttock, and a Stage I on his sacral area. - 7/29/10 - All pressure sores healed. - 9/7/10 - readmitted from hospital with Stage II pressure sores on his right and left buttock. - 9/30/10 - readmitted from hospital without any pressure sores. - 10/7/10 - 10/21/10 - No pressure sores. During an interview on 10/26/10 at 4:20 p.m., CNA E said she checked on Resident #5 when she started her shift at 2 p.m., but she had not repositioned him or offered him anything to drink. She said Resident #5 could not transfer himself to his wheelchair and needed extensive assistance with ADLs. During an interview on 10/27/10 at 1:15 p.m., the treatment LVN said she did not know Resident #5 was losing weight. During an interview on 10/27/10 at 12:20 p.m., LVN H said she provided care for Resident #5 from 10/25/10 - 10/27/10. She said she had not assessed his skin during that time. LVN H said on Monday 10/25/10, Resident #5's ears looked "a little red", but there were no open areas. LVN H said Resident #5 did not have any current pressure sores. During an interview on 10/27/10 at 1:06 p.m., CNA I said Resident #5 was dependent on staff for ADLs. CNA I said she had provided incontinent care for Resident #5 that day and last week (Friday 10/22/10). She said she had not "noticed" any skin breakdown on his buttocks. She said he did not have cushions for his oxygen tubing to help prevent friction or pressure on his ears. During an interview on 10/27/10 at 1:12 p.m., CNA J said she assisted Resident #5 with incontinent care, but she had not seen pressure sores. During an interview on 10/27/10 at 3:40 p.m., CNA A said Resident #5 was weighed once a week. CNA A said she was not told Resident #5 was to be weighed 3 times a week. CNA A said Resident #5's weekly weights for October 2010 were: 10/4/10 - 150.8 pounds 10/7/10 - 146 pounds 10/19/10 - 134.8 pounds 10/26/10 - 134.6 pounds During an interview on 10/28/10 at 3:00 p.m., the DON said she was aware Resident #5 had weight loss, but was not aware he had pressure sores and dietary intervention were not implemented. Resident #5's nutritional assessment dated [DATE] revealed the resident's fluid needs were 1500 - 2000cc per day and he was at moderate risk for compromised nutrition. Resident #5's most recent dietary progress note dated 9/10/10 revealed he was to receive a regular no added salt diet and usually consumed 75 -100% of his meals "per nursing notes." The progress noted did not address Resident #5's pressure sores. Resident #5's laboratory results dated [DATE] noted a low total protein at 5.1 with a reference range of 6.5 - 11.1 and a low [MEDICATION NAME] at 2.9 with a reference range of 3.5 - 5.0. According to the website, <http://www.webmd.com>, viewed 10/29/10, low [MEDICATION NAME] levels may be caused by a poor diet ([MEDICAL CONDITION]). According to http://www.npuap.org/PU_Prev_Points.pdf accessed on 11/9/10 pressure ulcer prevention points include: III. Nutrition - Identify and correct factors comprimising protein/calorie intake - Consider nutritional supplementation/support for nutritionally compromised persons The facility's undated "Elements of the Skin System" policy noted the following: Prevention and Treatment - Turning and repositioning - Nutrition and hydration a) Minimum of 30 cc/kilogram fluid to maintain hydration b) increase in calories and protein (needed for collagen synthesis, tissue remodeling) c) Multivitamin with minerals d) Dietician consult - Pressure redistribution/pressure relieving devices (gel cushions, air mattresses, bridging of heels) - Daily skin inspections by CNA, notify charge nurse of any changes - Protect elbows and heels from friction The CMS 672 dated 10/26/10 noted there were 60 residents receiving preventative skin care and 6 residents with pressure sores. During exit on 10/28/10, the facility was given the opportunity to present additional information. No additional information was provided.

Based on observation, interview, and record review, the facility failed to follow the physician plan of care for 1 of 5 residents sampled for weight loss (Resident #5). Resident #5 was to be weighed 3 times a week and the nurse practitioner was to be notified if the resident had a 3 pound weight loss or gain, per physician order. The resident was weighed once per week and had a 10.7% weight loss from October 4 to October 26, 2010. The nurse practitioner was not notified of the resident's weight loss. This failure contributed to continued weight loss for Resident #5. This failure could place 3 residents with weight changes at risk of not receiving needed services per the care plan. Findings included: Resident #5's October 2010 physician orders [REDACTED]. Resident #5 was to be weighed 3 times a week and the nurse practitioner was to be notified if he gained or lost 3 pounds. Resident #5's most current MDS dated [DATE] indicated he had no cognitive impairment. The resident was dependent on staff for ADLs and required supervision and cueing with meals. In an observation on 10/26/10 at 12:20 p.m., Resident #5 was in the dining room with his meal tray in front of him. The resident ate approximately 25% of his meal and drank approximately 50% of his tea after prompting by a charge nurse. In an observation on 10/27/10 from 1:15 p.m. to 1:45 p.m., Resident #5 was in his room eating lunch. The resident consumed approximately 25% of his meal and tea without prompting. During an interview on 10/27/10 at 12:20 p.m., LVN H said Resident #5 did not eat well and at times would refuse to eat because he was not hungry. She said the resident had to be cued during his meals. The LVN said she did not know if Resident #5 had weight loss. During an interview on 10/27/10 at 12:36 p.m., Resident #5 said he was not hungry and was not going to eat lunch. The resident said "I can tell I have lost some weight here recently." During an interview on 10/27/10 at 3:10 p.m., the DM said the nurses gave her communication sheets for residents with weight loss. She said every week the weight team, which consisted of the DON, speech therapist, SW, LVN K, and herself, met to determine interventions needed for residents with weight loss. The DM said she would change the diet and offer supplements as ordered by the physician. The DM said the DON or the nurses notified the dietician and physician regarding residents who with weight loss. She said CNA A was responsible for weighing residents. During an interview on 10/27/10 at 3:40 p.m., CNA A said Resident #5's weights during October 2010 were: 10/4/10 - 150.8 pounds 10/7/10 - 146 pounds 10/19/10 - 134.8 pounds 10/26/10 - 134.6 pounds During an interview on 10/27/10 at 4:00 p.m., LVN C said Resident #5 had a poor appetite and usually ate 25-50% of his meals. She said he occasionally refused meals and snacks. LVN C said Resident #5 had not received any appetite stimulants or dietary supplements. During an interview on 10/28/10 at 2:00 p.m., LVN C said she was not aware Resident #5 had weight loss. She said the last weight on the weight flow sheet indicated the resident weighed 150.8 pounds. During an interview on 10/28/10 at 3:00 p.m., the DON said she was aware Resident #5 had weight loss. She said the physician had not been consulted. The DON said, "We missed it and we should not have." The CMS 672 dated 10/26/10 noted 3 residents with unplanned/significant weight change. During exit on 10/28/10, the facility was given the opportunity to present additional information. No additional information was provided.

Based on observation, interview, and record review, the facility failed to consult the physician for 1 of 5 residents sampled for weight loss (Resident #5). The physician was not notified when Resident #5 had a 10.7% weight loss from October 4 to October 26, 2010. This failure contributed to continued weight loss for Resident #5. Additionally, this failure could place 3 residents with weight changes at risk for delayed medical evaluation. Findings included: Resident #5's October 2010 physician orders [REDACTED]. Resident #5 was to be weighed 3 times a week and the nurse practitioner was to be notified if he gained or lost 3 pounds. A telephone physician order [REDACTED]. Resident #5's most current MDS dated [DATE] indicated he had no cognitive impairment. The resident was dependent on staff for ADLs and required supervision and cueing with meals. In an observation on 10/26/10 at 12:20 p.m., Resident #5 was in the dining room with his meal tray in front of him. The resident ate approximately 25% of his meal and drank approximately 50% of his tea after prompting by a charge nurse. In an observation on 10/27/10 from 1:15 p.m. to 1:45 p.m., Resident #5 was in his room eating lunch. The resident consumed approximately 25% of his meal and tea without prompting. During an interview on 10/27/10 at 12:20 p.m., LVN H said Resident #5 did not eat well and at times would refuse to eat because he was not hungry. She said the resident had to be cued during his meals. The LVN said she did not know if Resident #5 had weight loss. During an interview on 10/27/10 at 12:36 p.m., Resident #5 said he was not hungry and was not going to eat lunch. The resident said "I can tell I have lost some weight here recently." During an interview on 10/27/10 at 3:10 p.m., the DM said the nurses gave her communication sheets for residents with weight loss. She said every week the weight team, which consisted of the DON, speech therapist, SW, LVN K, and herself, met to determine interventions needed for residents with weight loss. The DM said she would change the diet and offer supplements as ordered by the physician. The DM said the DON or the nurses notified the dietician and physician regarding residents with weight loss. She said CNA A was responsible for weighing residents. During an interview on 10/27/10 at 3:40 p.m., CNA A said Resident #5's weights during October 2010 were: 10/4/10 - 150.8 pounds 10/7/10 - 146 pounds 10/19/10 - 134.8 pounds 10/26/10 - 134.6 pounds During an interview on 10/27/10 at 4:00 p.m., LVN C said Resident #5 had a poor appetite and usually ate 25-50% of his meals. She said he occasionally refused meals and snacks. LVN C said Resident #5 had not received any appetite stimulants or dietary supplements. During an interview on 10/28/10 at 2:00 p.m., LVN C said she was not aware Resident #5 had weight loss. She said the last weight on the weight flow sheet indicated the resident weighed 150.8 pounds. During an interview on 10/28/10 at 3:00 p.m., the DON said she was aware Resident #5 had weight loss. She said the physician had not been consulted. The DON said, "We missed it and we should not have." The facility policy for a resident's change in condition dated January 2004 noted the following: - Our facility shall promptly notify the resident, his/her physician, and representative of changes in the resident's medical/mental condition and/or status. 1.) The nurse supervisor/charge nurse will notify the resident's attending physician or on-call physician when there has been: e. A significant weight loss/gain. The CMS 672 dated 10/26/10 noted 3 residents with unplanned/significant weight change. During exit on 10/28/10, the facility was given the opportunity to present additional information. No additional information was provided.

Based on observation, interview, and record review, the facility failed to provide services to prevent weight loss for 1 of 5 residents sampled for weight loss (Resident #5). Resident #5 had a 10.7% weight loss from 10/04/10 - 10/26/10. He was not weighed as ordered and the dietician and physician were not consulted about his weight loss. Resident #5 was not assisted with his meals. The resident continued to lose weight and no interventions to prevent further weight loss were implemented. This failure contributed to Resident #5's continued weight loss and dehydration. This failure could place 3 residents with weight changes at risk for decline in their nutritional status. Findings included: October 2010 physician orders [REDACTED]. Resident #5 was to be weighed 3 times a week and the nurse practitioner was to be notified if he gained or lost 3 pounds. Resident #5's most current MDS dated [DATE] indicated he was not cognitively impaired; he was dependent on staff for ADLs, and required supervision and cueing with meals. On 10/26/10 at 12:20 p.m., Resident #5 was observed sitting at the dining table with his meal tray in front of him. Resident #5 was not attempting to eat. Several staff walked past the resident without encouraging or cueing him to eat or drink. The resident ate approximately 25% of his meal and drank about 50% of his tea after he was encouraged several times by a charge nurse. Resident #5's nutritional assessment dated [DATE] noted he was at moderate risk for compromised nutrition. Resident #5's most recent dietary progress note dated 9/10/10 noted he received a regular no added salt diet and consumed 75-100% of his meals "per nursing notes." No recommendations were noted. Resident #5's care plans dated 9/30/10 revealed he was at risk for dehydration/fluid maintenance and compromised nutrition. The care plan included interventions to monitor for [MEDICAL CONDITION] and symptoms of dehydration; provide weights 3 times a week; and offer snacks and substitutes. The care plan goal was for Resident #5 to be well nourished and hydrated. A telephone physician orders [REDACTED]. During an observation and interview on 10/26/10 at 3:48 p.m., Resident #5 was lying in bed. He had food crumbs on his tongue and inner lips. Resident #5 said his mouth and lips were dry and he was "so thirsty." As he spoke, his lips stuck to his teeth and tongue. His lips were dry and cracked. Resident #5 said he had not had anything to drink since lunch and he said staff had offered him anything to drink. He said he could not walk and depended on staff to bring him something to drink or to put a drink within his reach. The resident said he did not know where the water pitcher was. He said he had not asked for anything to drink because staff had been in to check on him. During an interview on 10/27/10 at 12:20 p.m., LVN H said Resident #5 did not eat well and at times would refuse to eat because he said he was not hungry. She said he had to be encouraged and cued during his meals. She said the CNAs usually brought the residents something to drink or snacks. The LVN said she was not aware if Resident #5 had any weight loss. During an interview on 10/27/10 at 12:36 p.m., Resident #5 was in his room and said he was not hungry and did not think he was going to eat any lunch. Resident #5 said, "I can tell I have lost some weight here recently." During an interview on 10/27/10 at 1:06 p.m., CNA I said Resident #5 ate about half of his oatmeal for breakfast. CNA I said Resident #5 was dependent on staff for all ADLs. She said she did not offer him anything to drink or snacks after breakfast. CNA I said they were to offer fluids and snacks and encourage the residents to drink every time they were in a resident's room. During an interview on 10/27/10 at 1:12 p.m., CNA J said Resident #5 needed cueing and encouragement for fluid and food intake. She said she assisted Resident #5 with his breakfast that morning and he ate about 50%, but she had not offered him anything to eat or drink since. In an observation on 10/27/10 from 1:15 p.m. to 1:45 p.m., Resident #5 consumed approximately 25% of his meal and tea without prompting. At 1:45 p.m., CNA I removed Resident #5's tray from his room. CNA I did not prompt the resident to drink or eat anything else. During an interview on 10/27/10 at 3:10 p.m., the DM said the nurses gave her communication sheets of all residents with weight loss. She said every week the weight team, which consisted of the DON, speech therapy, the SW, LVN K, and herself, met to determine what interventions were needed for residents with weight loss. The DM said when she was notified by the nurses or the DON of residents with weight loss; she would change the diet and offer supplements as ordered by the physician. The DM said the DON or the nurses notified the dietician and physician of any residents experiencing weight loss. She said CNA A was responsible for resident weights. During an interview on 10/27/10 at 3:40 p.m., CNA A said the DON gave her a list of residents who had daily, weekly, or monthly weights and every week she turned in the weights to the DON. She said Resident #5 was weighed once a week. She said she was not told he was to be weighed 3 times a week. CNA A said Resident #5's weekly weights for October 2010 were: 10/4/10 - 150.8 pounds 10/7/10 - 146 pounds 10/19/10 - 134.8 pounds 10/26/10 - 134.6 pounds During an interview on 10/27/10 at 4:00 p.m., LVN C said Resident #5 had a poor appetite and he usually ate 25-50%. She said he occasionally refused meals and snacks. LVN C said Resident #5 had not received appetite stimulants or dietary supplements. She said the CNAs were responsible for offering him snacks and drinks. Resident #5's laboratory results dated [DATE] noted the following: - low total protein at 5.1 (6.5 - 11.1), and - low [MEDICATION NAME] at 2.9 (3.5 -5.0) According to the website, <http://www.webmd.com/hw-popup/dehydration viewed 10/29/10, low [MEDICATION NAME] levels may be caused by a poor diet ([MEDICAL CONDITION]). According to the website, http://www.labtestsonline.org/understanding,viewed 11/1/10, total protein level may be ordered to provide general information about nutritional status, such as a recent weight loss. In an interview on 10/28/10 at 2:00 p.m., LVN C said the DM made dietary referrals for residents identified with weight loss during their weekly weight meetings. LVN C said she was not aware if Resident #5 had weight loss. She said the last weight on the weight flow sheet indicated he was 150.8 pounds. She said she was not responsible for recording the weights on the flow sheets. She said she rarely had time to look at the weight flow sheets. During an interview on 10/28/10 at 3:00 p.m., the DON said CNA A turned in a copy of the weekly weights. She said Resident #5 had orders on 9/30/10 to be weighed 3 times a week and to notify the nurse practitioner of a 3 or more pound weight loss or gain, but he had only been weighed once a week. She said the order was overlooked. She said she was aware he had a weight loss. She said the physician had not been notified and dietary interventions were not implemented. The DON said, "We missed it and we should not have." The CMS 672 dated 10/26/10 indicated there were 3 residents with unplanned/significant weight loss. During exit on 10/28/10, the facility was given the opportunity to present additional information. No additional information was provided.